Of course that could mean does everyone deserve mediocre care or does everyone deserve the health care of royalty, free back massages, tummy tucks, costly experimental meds, you name it. And do they deserve it to be free or paid by someone else.

To make the answer - yes - I would ask it differently, does everyone in this country deserve the right to choose and purchase health care from the same menu of choices and costs?

Does everyone deserve to live in the largest mansion? Does everyone deserve oceanfront property? Does everyone deserve to dine in the same restaurant? Every night of the week? No, you have to earn, save and choose the best. Or you can make other choices. Some would rather live a block from the ocean and put the rest of the money toward something else. Does everyone deserve admittance to the best college? Does every golfer deserve Tiger's winnings? Does every man deserve to sleep with the planet's most beautiful woman?

We guarantee 'same' level of health care only by banning above average care. How does that make us better off?

Health Care is more equal in Europe but survival rates for the most likely ailments you could face are far worse:http://www.medscape.com/viewarticle/561737"Survival was significantly higher in the United States (than Europe) for all solid tumors, except testicular, stomach, and soft-tissue cancer, the authors report. The greatest differences were seen in the major cancer sites: colon and rectum (56.2% in Europe vs 65.5% in the United States), breast (79.0% vs 90.1%), and prostate cancer (77.5% vs 99.3%),

I suppose it depends upon the definition of "same level of healthcare".

Are you entitled to the same rich (low deductible, little out of pocket, PPO choice) benefit plan? I don't think so; that is what I think DougMacG was alluding to. Are you entitled to a short wait, fast service, and the very best doctors; probably not. But are you entitled to an MRI when your knee looks like a pretzel? Are you entitled to stay one more day in the hospital if you can't even stand up? Are you entitled to that expensive drug that may save you life or at least take away the pain? Are you entitled to a plastic surgeon after a car accident? A respected Orthopedic surgeon versus a resident? I don't know the answer, but if you don't have insurance in this country, too bad, you lose.

As for survival rates, DougMacG was a bit disingenuous. America, as it concerns very high cost treatment items like cancer is superb where star war technology rules. However, if you look at overall rankings of America's Health Care we are rarely in the top 10 and often are not even in the top 20 among industrialized nations. Plus on any chart our morbidity and mortality rankings are quite low. Yet we spend, by far, the greatest amount per capita on heath care. Still, the survival rates for the most likely ailments you could face are far worse in America.

Yes, if you are very rich, America is the place to be. Unfortunately, we are not all rich. And God help the person who had a good corporate medical plan, but was laid off and now cannot buy insurance. He'll soon be joining the poor after he sells his house and all his belongings.

In recent days, Barack Obama’s campaign has intensified its attacks on John McCain’s proposal for reform of our health-insurance system. Based on a spate of recent radio and television ads, and on the line Joe Biden took in last week’s vice-presidential debate, McCain should expect some sharp attacks against his bold proposal in this tonight’s debate. He should be ready to respond, because the attacks are either false or grossly distorted, and his plan deserves to be defended and touted.

The McCain plan begins by addressing the fundamental health-care concern of the middle class: that insurance is too expensive, too rigid, and too insecure. Rising premiums are pushing down take-home wages, the choice of insurance plans is made by the company and not by the family, and leaving a job means losing coverage in uncertain times. The solution, McCain argues, is to put more control in the hands of families rather than holding them hostage to their employers’ plans.

Today, most Americans have only as many insurance options as their employer provides — which is usually one, take it or leave it. This is largely a function of bad government policy. Federal law says that if your employer buys your insurance, the money he spends (which is taken out of your wages) is not counted as part of your income, and so is not taxed. But if you buy your insurance yourself, you do pay taxes on the money you use. For six decades, this has provided an enormous incentive to opt for employer-provided health insurance and has kept a real market for individually purchased coverage from developing. This is an enormous disadvantage for those who don’t have the option of employer-based coverage or who have needs that aren’t met by their employer-based plans.

The McCain plan begins by erasing the distinction between employer-provided and individually purchased health insurance. It replaces the existing tax deduction with a tax credit of $2,500 per person (or $5,000 per family) offered to everyone, regardless of whether their employer offers health coverage.

If you now get insurance from work and want to continue to do so, what your employer pays for your coverage will now count as income, but the credit will more than cover your additional taxes — you keep your coverage, and even end up with a little more money in your pocket at tax time. If you now get insurance from work but would rather choose a different plan — or if are dropped from your current coverage — the wages your employer now takes out for insurance would become regular cash wages, and together with the new tax credit will let you buy the insurance you want independently. Again, you end up with more options and more money at the end of the day. If you don’t have insurance today, or are getting it on your own, the tax credit will help you better afford it. In every case, you end up with more money, more options, and more control over your own health insurance.

Meanwhile, the McCain plan also seeks to vastly increase options and reduce costs by allowing competition in the insurance industry across state lines, which would allow many who are now uninsured to get private coverage. It would help protect vulnerable patients with preexisting conditions by expanding risk pools and by providing subsidies for private coverage for those with low incomes.

The Obama campaign’s attacks on the plan have been astoundingly dishonest. In last week’s debate, Sen. Biden claimed McCain’s plan would raise taxes on middle-class families, when every independent assessment has shown it would lower their tax burden. He argued it was tantamount to what has sent Wall Street into a tailspin — but the more accurate analogy to the mess in our housing market is the Obama health-care plan, which would have the government compete with private insurers and distort the market by confusing politics with economics just as Fannie Mae and Freddie Mac have done.

Indeed, the Obama campaign’s increasingly fervent attacks serve mostly to take attention away from the details of their own health-care proposals, which would price private insurers out of business, subsidize a government-run alternative, levy a heavy new tax on employment, and misspend many hundreds of billions of dollars just as we are entering difficult economic times.

Long-term, Obama’s plan amounts to putting the whole country on Medicare, which would reduce the quality of care, empower bureaucrats over doctors and patients, and, quite possibly, bankrupt the federal government. McCain’s plan envisions instead a competitive market for health insurance, which would give patients more options and more control, leave taxpayers with more money in their pockets, and ensure our thriving biomedical research industry an opportunity to keep developing new treatments and technology.

The McCain plan deserves a defender and champion this week, and John McCain should finally step up and become one in tonight’s debate.

For someone running as the tribune of "change," Barack Obama showed again in last night's debate that he sure is comfortable with the status quo on health care. He continued his recent assaults on John McCain's health reform even though it is precisely the kind of plan that someone of Mr. Obama's professed convictions ought to support.

APThe attacks include swing-state TV spots and Joe Biden's multiple distortions, though the most over-the-top come from the candidate himself. Over the weekend, Mr. Obama called the McCain plan "radical," "out of line with our basic values" and, in case he wasn't clear, "catastrophic for your health care." Since Mr. McCain offered only a once-over-lightly defense of his plan, allow us to give it a try.

Perhaps Mr. Obama is so agitated because Mr. McCain's proposal is highly progressive. The Republican wants to readjust the subsidies that Congress channels into health coverage for business so that lower- and middle-wage workers aren't shortchanged, as they are now. Currently, people who get insurance through their employers pay no income or payroll taxes on the value of the benefit. This is revenue the government forgoes to encourage certain behavior. If those losses were direct spending, the tax exemption would have cost more than $246 billion in 2007.

But all that money props up only employer-provided insurance. For reasons of historical accident and lobbying clout, individuals who buy policies get no tax benefits and pay with after-tax dollars. Mr. McCain is proposing to make the tax benefits available to everyone, regardless of how they purchase their insurance.

He would offer a refundable tax credit of $5,000 for families, $2,500 for individuals, and the benefit isn't dependent on where people work or what they earn. Some would stick with their current job-based coverage. Given the option, others -- especially the uninsured, armed with new health dollars -- would decide to buy coverage on their own. That in turn would stimulate a market for more affordable insurance.

Mr. Obama doesn't want to let people make this choice. He even claims it would amount to "taxing your health-care benefits for the first time in history," which is a wild distortion. His point seems to be that because companies wouldn't have to pay for health care, they could raise wages and thus taxes would also increase for workers on those higher incomes. But doesn't Mr. Obama want higher wages?

All in all, workers would come out ahead with the McCain plan. According to the left-leaning Tax Policy Center, the average taxpayer would see his tax bill drop by $1,241 in 2009. On average, lower-wage workers have more limited coverage as part of their compensation, mostly from small- or medium-size businesses. But the more generous the employer health plan, the more the tax subsidies increase. According to the Joint Committee on Taxation, the current employer benefit is only worth between $600 and $3,000 for people making under $100,000. The upper-income brackets save between $4,000 and $5,000.

The most affluent -- i.e., the top quintile of earners -- would be slightly worse off after 2013 under the McCain plan, though they'd still have plenty of options. Even as he routinely promises to raise taxes on "the rich," Mr. Obama is leaping to their unlikely defense here only to frighten everyone else. The McCain plan is fairer than the status quo, which subsidizes the most expensive employer (and union) insurance plans.

But don't take our word for it. Mr. Obama's chief economic adviser agrees with the McCain critique of the current system, or at least he once did. "This massive program of tax breaks is ineffective and regressive, wasting money on those who have health insurance while doing little for those who can barely afford it and nothing at all for those without it," wrote Jason Furman in 2006 in the journal Democracy. Before he joined the Obama campaign, Mr. Furman championed a health reform that relied on many of the same tax tools as Mr. McCain's.

In contrast to Mr. McCain, the Obama plan is all about expanding government health care. Mr. Obama is proposing a "public option" that is similar to Medicare but open to everyone of any age. With this new taxpayer-funded entitlement, private insurers would be crowded out as the government gradually paid all of the country's health-care costs.

Yet according to the Congressional Budget Office, federal spending on Medicare and Medicaid already takes up 4% of GDP today and will rise to an unsustainable 9% over the next two decades. Mr. Obama wants to add even more costs to this taxpayer balance sheet. The inevitable result as spending explodes would be price controls and rationing.

On choice, portability, quality and especially equity, the McCain health plan is far superior to Mr. Obama's. The Democrat is merely offering Canada on the installment plan.

Businesses Wary of Details in Obama Health Plan By KEVIN SACKPublished: October 26, 2008 AGAWAM, Mass. — Dave Ratner, owner of Dave’s Soda and Pet City, is pretty sure he is about to get “whacked” by the new state law that requires employers to contribute to health care benefits for their workers or pay a $295-per-employee penalty. In order to avoid thousands of dollars in fines, Mr. Ratner is considering not adding part-time workers at his four pet supply stores in Western Massachusetts.

But the penalty in Massachusetts is picayune compared with what some health experts believe Senator Barack Obama, the Democratic presidential nominee, might impose as part of his plan to provide affordable coverage for the uninsured. Though Mr. Obama has not released details, economists believe he might require large and medium companies to contribute as much as 6 percent of their payrolls.

That, Mr. Ratner said, would be catastrophic to a low-margin business like his, which has 90 employees, 29 of them full-time workers who are offered health benefits.

“To all of a sudden whack 6 to 7 percent of payroll costs, forget it,” he said. “If they do that, prices go up and employment goes down because nobody can absorb that.”

Writ large, that is one of the significant concerns about Mr. Obama’s health plan, which like this state’s landmark 2006 law would subsidize coverage for the uninsured by taxing employers who do not cover their workers. And it is a primary reason that so-called play-or-pay proposals have had an unsteady history for nearly two decades.

With Mr. Obama’s plan, business leaders say, the devil will be in the unknown details.

Mr. Obama would prohibit insurers from rejecting applicants because of medical conditions, require health insurance for children and create a new federal health plan to provide comprehensive coverage to the uninsured. Those beneath certain income levels would be granted tax credits to make premiums affordable, and small businesses would be offered tax credits to provide benefits.

The tax credits are projected to cost at least $110 billion. Mr. Obama has said he would pay for it primarily by raising income taxes on those making more than $250,000 and by reducing health spending. But when he announced the plan in May 2007, he emphasized that employers would share in the cost.

“We will ask all but the smallest businesses who don’t make a meaningful contribution today to the health coverage of their employees to do so by supporting this new plan,” he said.

Left undefined has been what size firms would be exempted, what constitutes a “meaningful contribution,” and how much noncompliant businesses would be required to pay. Senator John McCain, the Republican nominee, badgered Mr. Obama in two of their debates to define the penalty, but Mr. Obama did not rise to the bait.

“We made a decision even before the plan was rolled out not to decide,” said David M. Cutler, a Harvard economist who speaks for the campaign on health care. “It’s not that there’s a decision out there that we’re not telling. It’s literally that we’ve decided not to decide.”

That may be smart politics. But it makes business groups nervous that Mr. Obama might impose an unmanageable burden. They also worry that any time his health plan faces a shortfall, businesses will be asked to up their ante, as has happened in Massachusetts.

“Play-or-pay can become a blank check to an already overcapitalized health care system,” said Helen B. Darling, president of the National Business Group on Health, which represents 300 companies.

Business groups also have concerns that Mr. McCain’s plan to change the tax treatment of health benefits would erode employer-sponsored insurance.

Mr. Cutler said the Obama campaign regarded play-or-pay less “as a revenue raiser” than as a way of “leveling the playing field.” It would hold accountable those employers whose uninsured workers might seek treatment in emergency rooms or enroll in government insurance plans, with costs subsidized by others through higher premiums and taxes. Mr. Cutler said the expense to businesses would be offset by savings from Mr. Obama’s proposals to reduce health spending, though that is an uncertain prospect.

Several econometric models have assumed that Mr. Obama would have to set his penalty near 6 percent of payroll (Mercer, a benefits consulting firm says that large employers typically pay 15 percent). Recent play-or-pay proposals in California and Pennsylvania put the figure at 3 or 4 percent, and both failed in part because of business opposition.

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Hawaii is the only state that requires employers to provide health benefits, while Vermont, like Massachusetts, gently fines those who do not. Several other states have enacted similar laws over the last two decades, but they have been repealed, rejected by voters or challenged in court.

Economists believe the cost of health benefits is ultimately shifted to employees through lower wages. When wages cannot be lowered, layoffs may result. Katherine Baicker of Harvard and Helen G. Levy of the University of Michigan have projected that play-or-pay might push 224,000 workers into that category.When negotiating their health plan, Massachusetts lawmakers rejected a payroll tax and instead set a “fair share contribution” that was low enough to appease businesses. The amount also was kept low to steer clear of the 1974 federal law prohibiting states from regulating multistate group insurance plans. Companies with 10 or fewer full-time equivalent employees were exempted.

State officials hoped the penalty would generate a little revenue, but recognized it was not likely to prompt employers to start offering coverage. It raised only $7.7 million in its first year, well under projections. So when a substantial budget gap opened in the $869 million health plan this year, Gov. Deval Patrick asked businesses to help fill the hole.

He compromised on a revised formula that is projected to bring in $30 million by increasing the number and average size of firms that will be penalized. The state expects 1,100 businesses to be fined, up from 855, or about 3 percent of eligible companies.

The deal left business leaders satisfied for the moment. They recognize that the $295 penalty is a fraction of the $4,000 that Massachusetts employers spend to insure an individual worker.

But businesses worry the state will raise their obligation each year. They argue they have already absorbed costs of insuring 159,000 workers with group coverage since the state began mandating insurance (a total of 439,000 have enrolled, giving the state the country’s highest insurance rate).

“You want the system to work,” said Jon Hurst, president of the Retailers Association of Massachusetts. “You just want to make sure there isn’t more cost-shifting to businesses because they are paying their fair share.”

State officials are gratified that — contrary to national trends — the share of employers offering health benefits has increased slightly. One fear about play-or-pay is that if the penalty is too low employers will stop offering coverage and pay the fines instead, shifting workers to government insurance programs.

But leaders here also are sensitive to the possibility that further increases in the penalty might stymie wage and job growth.

“In this day and age,” said Dr. JudyAnn Bigby, the state secretary of health and human services, “it wouldn’t take much of a change in policy to push some entities over the brink.”

Cutler and there is another Massachussetts liberal type - his name eludes me now - are getting everyone covered first and figuring about how to pay for it later. Right or wrong I don't know but they are not being honest with all the ramifications of what they advocate. But what else is new with liberals?

Health spending will not be reduced by expanding coverage to all without increasing people's personal responsibility for the costs as well. I don't hear them say anything about this. Not one iota. Amazing isn't it?

The fastest way to reduce the costs of health care is to transfer costs to patients. You would be surprised how quickly people will refuse tests not absolutely necessary or opt for generics as soon as they learn they will have to pay more.

But there is some blame for all. The insurers, the providers (doctors and hospitals), administrators, politicians, pharmaceuticals, device makers, acadamia, lawyers, cottage industries and more.

I think Americans call these entitlements . I'm canadian so the concept of being turned away at a hospital for monetary reasonsis completely foreign to me. Over crowding yes but not for lack of cash

Do you think your personal wealth should dictate whether your child should live or die?

I find this odd in that The Dog Brother culture is based on the community of the tribe or is it a pack

As a tribe you work together to become stronger you protect the little ones so that they have a chance to grow up to become productive members of the pack

You protect the elderly and infirm because they are your source of knowledge

Even in a pack wolves they protect the young and an older less able pack member is left at the den to guard the pubs or so I' told

Universal health care is not an "entitlement" it is a community decision to look after one another

The US is the only G8 country that does not provide some form of universal health care

I make a good wage and pay a boat load of taxes much more than it would cost for my once yearly trip to the doctor

but when accidents happen like when i tore the cartilage in my knee competing in Bjj in Brazil.

The system was there for me. I saw my GP took a weeks to get in. He refered me to a specialisttook 3 months to see him . Sent me for a MRI 6 weeks, another consultation with the specialist and he booked me for surgery in 6 weeksgot fixed, got some physio, went back to brazil the following july and won.Total cost to me 0 becuse my employer pays for more health care insurance.Other wise a couple of 100 for meds, physio and a chiropractor.Now if that would have happened in the US in lets say the 1980 during the recession when i was an unemployed studentand both my parents had lost there jobs. I would be still limping today.I can tell you similar stories about the various broken finger, concussions and nasty infectionsthat were dealt with before they become serious because as an unemployed student all I had to do was go to the local medical clinic and wait my turn

I was told in the US I could have had done in two weeks for 5000. If you are rich no need to wait your turn?

I consider myself a libertarian not interested in being surveilled, counted or have the government telling what to read or who to associate with, who i can marry or what substance in can put in my body.I don't want the government listen to my phone calls, reading my mail or seeing what crazy things i look up on the interweb or seeing how i spend my money

But what about my community.

Do my taxes benefit the community?

I say yes because if i had to make a choice between my daughter getting medical attention that would save her life and committing a crimeI think i would be a criminal and crime is an act against the community.

I see universal health care as a decision to strengthen your communityis Canada's system perfect hell no its rationed health care but if you are rich you can always go to the US

I am about to OD on forum matters so I will be a bit briefer than your question deserves:

No one is talking about letting someone without money die from car accidents etc.

I would draw attention to your apparent notion that it is morally superior to turn people away for overcrowding as versus turning people away for insufficient money. What is your reasoning here?

Denial of service due to overcrowding--due to virtually unlimited demand and diminished supply-- is precisely what happens when a good such as health is made "free"-- which in part is what is meant when we say "If you think health care is expensive now, just wait until the government makes it free." (PJ O'Rourke) At the moment, in Canada you do not suffer the full consequences of your course of action precisely because you live next door to us.

Let me tell you a story of an experience of mine:

In 1992 I had a freak BJJ accident wherein the ACL, PCL, and Lateral Collateral Ligaments of my left knee were snapped in half. Thanks to the wonders of modern medicine, what 5 to 10 years previous to that would have left me seriously gimp for life was fixed during the course of three surgeries which replaced the snapped ligaments with tendons from cadavers. INCREDIBLE! The cost was nearly $50,000 (remember this was 1992-93 dollars) Because I bought health insurance, I was out of pocket $5,000 and the insurance company paid the other $45,000.

THE SYSTEM WORKED - BECAUSE I WORKED AND TOOK RESPONSIBILITY FOR MYSELF.

OTOH, if Hillary Clinton and her health care program had been in charge, they probably would have decreed that there were too many specialists making too much money (this was a favorite point of hers) and there probably would not have been the specialists and the technology capable of saving my knee--- and my life in martial arts.

THAT IS WHAT UNIVERSAL HEALTH CARE MEANS TO ME.

Furthermore, I used to be a lawyer in Washington DC, so I have a very visceral sense of the human beings who would be the bureaucrats deciding whether I was allowed to get a particular treatment are. They are slow, vapid, and basically don't give a fcuk. As a free man in a free country, giving such people control over how I pursue my health is a bitter anathema.

IMHO it is important to understand that the clusterfcuk we have now is NOT the free market and most of its undesirable features can be traced rather directly to government intervention.

That's all I have time for right now. I hope it helps explain my perspective.

Researchers at Brigham Young University, the National Bureau of Economic Research and the Brookings Institution have found that health insurance mandates raise the price for everybody. As the press release describing the study explains:

New research shows that the cost of health insurance for a typical family increases about $100 per month when state governments limit price adjustments based on factors like age, health or risky behaviors such as smoking.

The finding by Brigham Young University economist Mark Showalter is one of several examples of how one state's set of rules can result in widely different prices than what's found in the state next door. Perhaps the most eye-opening contrast exists in Trenton, New Jersey, where premiums cost about twice as much as those sold across the Delaware River in Pennsylvania...

Seven states prevent insurers from adjusting prices based on one or more factors like age, health status or risky behavior. The researchers found such rules - known as community ratings - increased family premiums between 21 and 33 percent.

The rule is intended to promote equity but may consequently make insurance too expensive for healthy people. The study found New Jersey's strict form of community ratings responsible for premiums set two to three times higher than if the requirement were not in place.

Who knew that 1800 federal and state mandates would boost the price of health insurance? Well, actually, lots of analysts do. For example, Harvard business school professor Regina Herzlinger told reason:

"It's like I'm shopping for a car and my state mandates that all cars have heated seats," says Herzlinger. Car buyers would not long stand for a heated car seat mandate that raises the price of a car by $1,000, and similarly individual health insurance shoppers would object to unnecessarily expensive insurance mandates.

It is very likely that legislators rarely consider the costs of such mandates to consumers, so the good news is that the study now quantifies them so that these trade-offs can be made explicitly. Whole press release for the study is available here.

Health Insurance Premiums Rise Up To 33 Percent With State Pricing Rule, USA

18 Nov 2008

New research shows that the cost of health insurance for a typical family increases about $100 per month when state governments limit price adjustments based on factors like age, health or risky behaviors such as smoking.

The finding by Brigham Young University economist Mark Showalter is one of several examples of how one state's set of rules can result in widely different prices than what's found in the state next door. Perhaps the most eye-opening contrast exists in Trenton, New Jersey, where premiums cost about twice as much as those sold across the Delaware River in Pennsylvania.

"Establishing the actual costs of specific state regulations informs discussion of how to make health insurance more affordable," Showalter said. "It helps present a picture of what would happen if consumers were allowed to buy insurance from other states."

Showalter began the research during an appointment as a senior economist for the U.S. Council of Economic Advisers. He co-authored the new study with Amanda Kowalski of the National Bureau of Economic Research and William Congdon of The Brookings Institution. Their report will appear later this month in the academic journal Forum for Health Economics & Policy.

The researchers analyzed prices offered state-by-state for the estimated 26.5 million Americans who purchase directly from insurers rather than through an employer.

Seven states prevent insurers from adjusting prices based on one or more factors like age, health status or risky behavior. The researchers found such rules - known as community ratings - increased family premiums between 21 and 33 percent.

The rule is intended to promote equity but may consequently make insurance too expensive for healthy people. The study found New Jersey's strict form of community ratings responsible for premiums set two to three times higher than if the requirement were not in place.

University of Minnesota health economist Roger Feldman, who was not involved with the study, is funded by the U.S. Department of Health and Human Services to figure out how an interstate market might reduce the number of uninsured Americans.

"This study enables us to predict the effect of allowing consumers to shop for insurance across state lines," said Feldman. "Those kinds of simulations would not be possible without this study."

The researchers also found that health insurance premiums rise 10 percent or more when a state government makes insurers accept all doctors, hospitals or pharmacies instead of steering customers to an exclusive network of providers.

Twenty-one states have laws that require insurers to allow a patient to buy prescription drugs from any pharmacy they choose. Seven of those states force insurers to offer the same flexibility with choosing a doctor or hospital. According to the study, these laws result in a typical family paying about $30 more per month for health insurance.

Data for Showalter's study came from two major health insurers that do business nationwide. The analysis took into account factors that vary by location, such as the cost of health care, state taxes and consumer demographics.

"All of the regulations we studied have presumed benefits," Showalter said. "Our goal was to quantify the costs so that policymakers can better weigh the two."

A BYU alumnus, Showalter received a Ph.D. from the Sloan School of Management at the Massachusetts Institute of Technology. In 1991 he joined the BYU Economics Department faculty and has since published many journal articles on health and education.

The Obama Health Plan Emerges Article more in Opinion »Email Printer Friendly Share: Yahoo Buzz facebook MySpace LinkedIn Digg del.icio.us NewsVine StumbleUpon Mixx Text Size "Universal" government-run health care proved too ambitious even for FDR, who stripped it out of the Social Security Act of 1935. Lyndon Johnson settled for Medicare and Medicaid. Now liberals think the political moment has finally arrived to achieve what has eluded every other Democratic President from Harry Truman to Bill Clinton.

APOne signal is yesterday's news that Barack Obama has selected Tom Daschle, the very liberal former Senate warhorse, to head the Health and Human Services Department. But a even clearer sign was last week's release by Montana Senator Max Baucus of a policy blueprint that closely resembles the one Mr. Obama campaigned on for 17 months. The plan is significant not only because its author is Chairman of the powerful Finance Committee, which oversees taxes and about half of all government spending. Mr. Baucus is also one of the more moderate, and cautious, senior Democrats.

If the Obama White House decides that reorganizing the 17.1% of the economy that the U.S. is likely to spend on health care in 2010 is a first-year priority, then Mr. Baucus's bill will be the place they start. Americans need to learn what they'd be paying for.

First, Democrats want the government to create a national insurance exchange, or marketplace, in which all comers could buy into a range of heavily regulated private policies at group rates. These private plans would then "compete" with a new public insurance option, i.e., a program managed by the government and modeled after Medicare. Lower-income earners would get subsidies to make coverage "affordable." Businesses that didn't cover their employees would pay a tax on some portion of their payroll.

The last cog is the "individual mandate." This requirement that everyone buy coverage has grabbed most media scrutiny of the Baucus plan, because Mr. Obama opposed it during the campaign. But the many moving parts don't work together unless the young and healthy foot the bill for care of the older and sicker -- one reason Hillary Clinton kept nagging Mr. Obama about the individual mandate during the primaries.

The irony is that the public option -- not the mandate -- is far and away the most radical part of the plan. Green eyeshade objections are obviously out of favor in modern Washington, but the reality is that the Baucus-Obama plan would be extraordinarily expensive as it slowly but relentlessly grew the government's share of health spending. The draft doesn't include an exact cost, though casually notes the ballpark "investment" could run as high as $150 billion a year.

Even those huge outlays are likely conservative, considering that subsidies would go to families earning up to 400% of the federal poverty level. According to the Census Bureau, that would apply to 61.5% of the American population, or about 184 million people -- less those already on Medicare and Medicaid.

Some financing will come from the "pay or play" tax on businesses, but because Mr. Baucus is no more omniscient than anyone else, the tax rate is left undefined. If it is too low, companies will have every incentive to "cash out" their employee liabilities and pay the tax instead. Then workers will flood the public option.

The Baucus plan expects to make up more of the money with nips like better health technology and tucks such as "a national focus on wellness." But those don't come close to adding up to $150 billion -- or the health system would have made them already. As for the claim that centralizing health spending will lead to more "efficiency" . . . well, that is the triumph of hope over evidence.

Over the past 40 years, per capita health spending has grown an average of 2.1 percentage points faster than the economy. The dominant U.S. insurer -- Medicare -- has had no success in mitigating this climb, despite valiant attempts. Since the 1980s, Medicare has actually controlled the prices that physicians and hospitals are paid for thousands of billable services. In 2007, the program spent some $425 billion according to these arbitrary guesses. Because of its huge purchasing power, and because many private plans adopt its reimbursement rates, Medicare significantly shapes all health-care financing and delivery.

Now the Democrats want to double down with the public option, apparently on the theory that the bureaucracies fail only when they're too small. Even without the new program, Medicare and Medicaid costs are rising substantially both as a share of the economy and the federal budget. The nearby chart tracks the historical behavior of government health spending and the Congressional Budget Office's post-2007 fiscal scenario in the absence of reform. Today, health entitlements account for 4% of GDP but will rise to 7% in 2025 and about 15% in 2062.

Not that the current level of benefits will ever be paid. According to the Medicare trustees, the program's excess costs over the next 75 years -- that is, the difference between expected outlays and revenues -- is more than $36 trillion, which even they acknowledge is several trillion too low given current trends. Even if Congress doubled all individual and corporate tax rates, it still wouldn't raise enough revenue to pay for Medicare and Medicaid.

The Obama-Baucus solution to this slow-motion catastrophe is to add tens of millions more people to the federal balance sheet. Because the public option will enjoy taxpayer sponsorship, it will offer generous packages to consumers that no private company could ever afford or justify. And because federal officials will run not only the new plan but also the "market" in which it "competes" with private programs -- like playing both umpire and one of the teams on the field -- they will crowd out private alternatives and gradually assume a health-care monopoly.

Many proponents of plans similar to Mr. Baucus's openly cite this as one of their goals. Eventually, the public option will import Medicare's price controls into the private sector as it tries to manage the inevitable cost overruns. When that doesn't work, Congress will deal with the problem by capping overall spending and rationing care through politics (instead of prices) -- like Canada does today.

Either Senator Baucus and President-elect Obama are making promises that can't possibly be kept. Or they're not being honest about their plans for U.S. health care.

***the public option will import Medicare's price controls into the private sector as it tries to manage the inevitable cost overruns. When that doesn't work, Congress will deal with the problem by capping overall spending and rationing care through politics (instead of prices) -- like Canada does today***

Medicare's price controls? Is some cases Medicare is preferred by providers as opposed to some of the commercial carriers.

***The Baucus plan expects to make up more of the money with nips like better health technology and tucks such as "a national focus on wellness." But those don't come close to adding up to $150 billion -- or the health system would have made them already. As for the claim that centralizing health spending will lead to more "efficiency" . . . well, that is the triumph of hope over evidence.***

The idea that converting to electronic recods will cut the necessary inefficiencies out to the extent we are saved is a fantasy.

I got to laugh when Newt and others sit in front of the camera and say all we need to do is centralize the information and costs will stop increasing. While I agree it is a good idea and must be done in some way I beg to differ that it will save the future of medical care.

As for "wellness" - there are some preventative things that are done that save long term costs and there are others that actually drive up long term costs.

Without rationing health care costs will continue to skyrocket. Specialists who do procedures are whing because they can't charge the exorbitant fees they were bilking form the system for years. and those specialists who don't preform procedures have trouble paying bills. As for primary care folks like me - well the whole field is collapsing. You all may very well be seeing nurses instead of primary doctors from now on.

I spoke to one physician recently who was praying for total nationalization of health care. He feels anything is better than dealing with multiple insurances, patients without coverage etc. One national medical organization I know was ecstatic that Tom Daschle is picked for Sec of HHS. They feel he is on their side with regards to saving primary care which may soon be as obsolete as GM,Ford,Chrysler.

I am still not for nationalization. But the public I am afraid is not facing the truth about rationing. They still want everything possible especially as long as someone else covers it.

GPs often do not send enough patients for testsMore than 10,000 people die needlessly each year because their cancers are not diagnosed in time, a study says.

The charity Cancer Research UK found GPs too often miss symptoms or do not send enough patients for tests.

In some cases their training is simply out of date. The report says some people are deterred from seeking treatment by the difficulty of getting an appointment.

And there is too little public awareness about cancer symptoms, meaning many victims do not see their GP until it is too late to save their lives. The result is that Britain's survival rates for cancer are still the worst in Western Europe, despite the billions poured into the Health Service by Labour.

Only 53 per cent of women and 42 per cent of men with cancer survive for more than five years.

Of 14 major countries compared by the charity, Britain came 11th for women and 12th for men, alongside Poland and Slovenia. If our rates were as good as the best in Europe, the report says, there would be 10,744 fewer deaths a year.

Lead researcher Professor Michael Coleman said: 'We know many cases are being diagnosed too late and this is a major reason for our poor survival rates.'

He said many GPs were not up to date on cancer treatment, and family doctors with an average practice size saw only around eight new cancer cases a year.

'Some GPs would benefit from guidance on identifying patients more successfully,' he said.

Another problem was access, said Professor Coleman. 'Patients find it difficult to make appointments or park their cars, and many are worried about taking time off work and losing money.'

Only a half of GP practices see patients outside working hours - and even these open for an average of only three more hours a week.

Survival ratesThe failure of GPs comes despite their pay soaring by more than 50 per cent - to over £100,000 - since a new contract was agreed in 2004.

They are also working fewer hours a week.

Better survival rates in Europe are partly due to the fact that patients in many countries can have direct access to a specialist, while in Britain they must go through their GP.

The Government's cancer 'czar', Professor Mike Richards, said: 'We want to work with GPs to find out which patients and which symptoms they are most likely to miss. They need to be more alert and send people for tests much earlier.'

Britain's poor record has also been blamed on drug rationing by NICE - which can take up to 18 months to decides whether the NHS should fund new treatments - and low spending on cancer drugs, £76 a head a year, compared to £143 in Germany and £121 in France.

Professor Karol Sikora, professor of cancer medicine at London's Imperial College, said last night the low survival rates were a failure of the whole NHS, not just GPs. He said: 'People have to wait too long for scans and biopsies. There is undercapacity in radiography and chemotherapy.

'We don't get access to the drugs they get in Europe. Huge amounts of money have been thrown at cancer over the past decade so it is surprising to see these problems are still here.

The article points out that cancer is being diagnosed too late in Britain but it is not at all clear why.Are patients getting their screening tests? Are they being offered? Is it the delay in confirmatory testing and eventual referral to specialist?

Many studies also show that more screening does not equate to better care or longer survival. In fact many studies show that more screening makes for more problems. There are relatively few screening test that are clearly supported by evidence of having net benefit. For every total body scan one might want to do to look for a lurking cancer we will find two dozen other things that will warrant more tests, biopsies, anxiety and money that would never have been a problem. We could also do screening up the wazoo till the nation goes bankrupt. There is a balance.

Access to specialists is important and should be easy. Yet patients who run to different speicalists do wind up getting more tests (especially if the specialist has the test in their office and can bill for it - usually reasonable but clearly overdone at times) get fragmented care.

In this country nurses are replacing primary care doctors so one could argue there will be more opportunity for diagnoses to be missed. But some simple care they probably could do. I notice patients of mine who go to local walk in clinics for colds are invariably getting antibiotics though invariably it is uncommon they really need them. I try to talk my patients out of it. In these clinics that are more concerned for generating customer satisfaction they are all getting antibiotics because the patients think they need it. They are now contributing to further use of antibiotics and the problem of resistance.

Bobby Jindal, Louisiana's prodigy Governor, has been arguing lately that only policy innovators will break a path out of the GOP's political wilderness -- and he is leading by example. Mr. Jindal recently announced a major renovation of the way his state provides health coverage to the poor and uninsured, thus taking up a topic for which most Republicans require a shot of epinephrine just to pay attention.

APGov. Bobby JindalName any health criteria, and Louisiana is probably scraping bottom. According to one national ranking, the state was 49th in health outcomes in 2007 and worst overall in 2006. Even though about a quarter of the population is enrolled in Medicaid, another quarter is uninsured. Even though the federal government's "matching rate" pays out 71% of state Medicaid costs, state spending has doubled to 16% of the general budget over just the last two years. That share is projected to rise to 22% by 2011, swallowing funding for schools, police and other priorities.

Governor Jindal plans to steer working-poor Medicaid recipients out of the current "fee for service" program, where the state pays a set rate for all health-care charges (some 54 million this year). Instead, they'd choose among private managed-care plans, with Louisiana paying a fixed per-patient amount, adjusted for health risks. Essentially, Mr. Jindal wants to use Medicaid dollars to fund something like private insurance. That way, physicians and hospitals will be compensated for outcomes -- rather than volume of visits and procedures -- and get incentive payments for good performance.

Such a "defined contribution" plan is one way to wrestle run-amok health costs back under control and spend more responsibly. It isn't a new idea, but it is a good one. Congressional Republicans passed a similar reform in 1995 for Medicare, which Bill Clinton vetoed -- only to have his own bipartisan commission endorse it in 1999.

The Fed Is Out of Ammunition – Christopher WoodWhat a Single Nuclear Warhead Could Do – Brian T. KennedyChange Our Public Schools Need – Terry M. MoeBush Does the Right Thing for Darfur – Kenneth RothSince Louisiana will increase the value of its Medicaid dollars and free up other funding, it will also be able to expand eligibility. The initiative will start with about 380,000 people in New Orleans, Baton Rouge and two other regions, with the rest of the state integrated over the next five years. The hope is that by integrating fee for service's separate silos and realigning incentives, the quality of the delivery system will also improve.

Medicaid allows states the flexibility to experiment like Mr. Jindal, but it requires a federal waiver. Currently, Louisiana's negotiations are hung up on $771 million that the feds claim the state owes, much of it in alleged "overpayments." States often game the system to filch federal money they don't deserve, courtesy of national taxpayers. But in this case, Louisiana ought to get credit for good behavior, especially considering that Mr. Jindal inherited the problem. In any event, the state only wants to pay back Medicaid over a longer term while producing savings compared to the status quo.

The Bush Administration's go-ahead is also a matter of urgency. If the talks aren't wrapped up soon, Mr. Jindal will be forced to start over with Barack Obama's team, which will be hostile to reforms that bank on the private sector. Either way, just the transition itself could delay things for six months or a year or more.

Congress is currently considering a state Medicaid "bailout" as part of its second stimulus package, in which Washington would pay for an even greater share of state health spending. That would reward the most spendthrift states. Mr. Jindal's proposal is a far better idea.

Agree with Jindal about innovation. We need more like him. Romney sounded good over the weekend talking about Detroit.We don't need more pundits like Laura Ingram - *my way or the highway*.

***physicians and hospitals will be compensated for outcomes -- rather than volume of visits and procedures -- and get incentive payments for good performance***

There is ongoing research on this model now by many groups. Many different interests from providers, insurers, government, vendors, pharma, pharmacies, patients, cottege industries.Its premature to say how this is going to work. In theory there are pros and cons, but I like the idea and hope it will have value to all. Early results suggest it will.

"physicians and hospitals will be compensated for outcomes -- rather than volume of visits and procedures"..."There is ongoing research on this model now by many groups. Many different interests from providers, insurers, government, vendors, pharma, pharmacies, patients, cottege industries. Its premature to say how this is going to work. In theory there are pros and cons, but I like the idea..."

My daughter's orthodontia (braces) is set up this way. One lump sum / payment plan all specified up front, includes the full program. Excludes certain things especially any service needed from others such as the dentist or oral surgeon. No additional charge for minor follow up visits scheduled or unscheduled. Somehow they cover it out of the first six grand. You don't ever have to second guess motives on how often to come in. And they don't get started in a service that isn't financed to completion - like a house.

For all my whining about the cost I have my (14yo)daughter considering orthodontics as a profession.

Hi Doug,Bundling the service for a health problem into one overall cost irregardless of number of visits, phone calls, etc is part of it.I am just going by experience and my study of the situation but am not an expert:

There are different ways of bundling. Surgeons are usually bundled by procedure - say they get a lump sum that includes visits and procedure for hernia repair. Others are capitated - that is they get a lump sum from the insurer to provide all care to a patient. I am not in favor of this because the financial incentive is for providers to do as little as possible since they earn the same either way.Another would be boutique medicine wherein a doctor provides all care (availability, visits, hospital, etc) to a patient for a specified monthly or yearly fee billed directly to a patient.

The main concept of *outcomes*, is bonus pay in getting patient to their target goals based on national standards. Say more pay for physicians if there patients blood pressures are where they should be and not over the goal for example. Other outcomes I guess could be patient satisfaction, screening tests recommended as per national guidlines, preventative care etc.

The idea is to base reimbursement partly on measured performance rather than just on how many patients or procedures one does.Reimbursement for quality and not just quantity I guess would be another way to put it.

As of right now those doctors who do procedures are compensated far more than doctors who do cognitive types of care whether specialist or primary.

A charismatic Democratic President takes office promising to extend health insurance to all Americans. His party enjoys majorities in Congress, and the GOP is at sea. The press corps finds policy a bore and instead files stories that draw facile analogies to the heyday of FDR.

APYes, all that will be true next year -- but it was also true in January 1993. Fewer than two years later, the grand health-care ambitions of Bill and Hillary Clinton were reduced to tatters. No one is more attuned to this memory than today's Democrats, who aren't about to let history repeat itself. And since the lessons they learned from the HillaryCare fiasco are political, and not substantive, they are already moving full-speed ahead.

This mentality is nicely captured by Tom Daschle, the former Senate Majority Leader who Barack Obama has tapped to run Health and Human Services. "I think that ideological differences and disputes over policy weren't really to blame," he writes of 1994 in his book "Critical," published earlier this year. Despite "a general agreement on basic reform principles," the Clintons botched the political timing by focusing on the budget, trade and other priorities before HillaryCare.

President-elect Obama will not make the same mistake. Congressional Democrats are already deep into the legislative weeds, while Mr. Daschle is organizing the interest groups and a grassroots lobbying effort. Mr. Obama may be gesturing at a more centrist direction in economics and national security, but health care is where he seems bent on pleasing the political left.

According to Mr. Daschle, because of the Clintons' hesitation, "reform opponents succeeded in confusing and even frightening Americans about what change might mean," and this time the Democrats mean to define the debate. Consider the December 2 letter to us from Senator Max Baucus, who is upset that a recent editorial on his health-care plan did not use his favorite terms of art (his style being surrealism). "It will require affordability, but premiums will not be set," he writes. So the government will merely determine "affordability" -- which might as well be the same thing.

Much as Mrs. Clinton insisted that her health bureaucracies were "alliances," Mr. Baucus says his new entitlement "will not be 'managed by the government,' but by an independent council of Presidentially appointed health-care experts." The Senate Finance Chairman wants us to believe that a government commission to determine benefits and subsidies will somehow be above politics.

Shrewder moves are being made to co-opt should-be opponents. The Clintons decided to go to war with "proponents of the status quo," as Mrs. Clinton put it in a bare-knuckled speech in May 1993. This meant vilifying business, especially insurance companies guilty of "unconscionable profiteering" and even drug makers like Merck, which Mr. Clinton had courted during his campaign. This time, Democrats are trying to seduce business with subsidies and other bribes.

They may succeed, which is no surprise given that many corporations would be only too happy to dump their health liabilities on the government. The "Divided We Fail" coalition, which advocates "universal" coverage, includes not only usual suspects like unions and AARP but also the Business Roundtable and the National Federation of Independent Business, the small-business lobby that led the charge against HillaryCare.

America's Health Insurance Plans, the industry trade group, recently said its members would accept all comers regardless of health status or previous illness -- i.e., guaranteed issue -- but only if the government requires everyone to buy insurance. The individual mandate will expand their business in the short term, but it won't be long before Congress is also regulating premiums, cost-sharing and administrative expenses. Dr. Faustus, call your internist.

Main Street: Now for an Honest Debate on Gitmo – William McGurnGlobal View: Obama's Team of Conformists – Bret Stephens

COMMENTARY

Getting Out of the Credit Mess – Harvey GolubRestore the Uptick Rule, Restore Confidence – Charles R. SchwabHolding CEOs Accountable – Jonathan MaceyAnother opening for Democrats is the new director of the Congressional Budget Office, a post vacated when Peter Orszag joined the Obama Administration. CBO totes up the official cost of legislation and thus is one of those obscure Beltway outfits that frames the political argument. A "score" that is too costly make a bill harder to pass.

In the 1990s, CBO director Robert Reischauer knee-capped HillaryCare by pointing out its true costs and giving little credit to claims it would generate savings. With good reason: Putative cost "offsets" never seem to materialize when Congress tries to plan the insurance markets. Now Democrats will try to install a CBO director who can be more easily rolled.

Most disturbingly, Democrats are talking up "budget reconciliation" to pass a health overhaul. This process was created in 1974 and allows legislation dealing with government finances to be whisked through Congress on a simple majority after 20 hours of debate. In other words, it cuts out the minority by precluding a filibuster. Mr. Daschle writes that reform "is too important to be stalled by Senate protocol," and Mr. Baucus has said he's open to the option.

Any taxpayer commitment this large ought to require a social consensus reflected in large majorities, but Democrats are determined to plow ahead anyway. They know that a health-care entitlement for the middle class will never be removed once it is in place; and that government will then dominate American health-care choices for decades to come. That's all the more reason for the recumbent GOP to get its act together.

The soda tax does not make much sense. There is ZERO evidence that people who stop drinking soda alone will lose weight. There is even some evidence (in animals) that the calorie free sodas with the artificial sweeteners actually cause weight gain.

Leave it to a crat to lay awake at night to dream up ways to rip us off. As for the health care cuts it wouldn't hurt if we get rid of the illegals who contribute to putting hospitals out of business by usuing ER services. No mention of that of course.How about taxes on political contributions? How about windfall profits taxes on the incomes of any politician above whatever it was before they took office?

How about a tax on all white men? That would be fair. How about taxes from government employees unions?

By JAMES M. ODATO, Capitol bureau Click byline for more stories by writer. First published: Sunday, December 14, 2008

New taxes, deep cuts to education and health care, and a restructuring of the state's economic development programs will be hallmarks of Gov. David Paterson's first budget plan to be released in two days, according to interviews of people briefed on components.The plan will come with a host of revenue raisers — increased taxes on hospitals and insurance policies, for instance — and at least one new assessment, a so-called obesity tax on non-diet soda to raise $404 million. The governor also is contemplating requiring new license plates to raise cash, reviving sales tax on clothing purchases, removing the tax cap on gasoline and threatening to require Indian retailers to collect taxes on sales to non-Indians by signing into law a bill passed earlier this year by the Legislature.

Paterson will unveil the spending plan, aimed at closing a $12.5 billion deficit for next year, on Tuesday. The total size of the Paterson budget is unknown.

There is no word on Paterson's plans for the state work force, although he has said he will adhere to a strict hiring freeze while looking to consolidate some components of government.

The cuts will be across the board and will build upon a deficit reduction plan Paterson proposed in November as he attempted to close the $1.5 billion shortfall in the $120 billion budget negotiated for this year. The plan was inherited from the executive budget introduced last January by Gov. Eliot Spitzer.

The health industry will be particularly upset, although Paterson's cuts will raise blood pressure throughout. He will call for about $3.53 billion in health care cuts, not including federal share of matching Medicaid dollars, which could be another $2 billion in cuts.

The biggest hits will be to insurance companies, which will be asked to come up with about $855 million in extra assessments. Those amount to more taxes on health insurance plans, increased sales tax on hospital discharges and more shifting of general fund costs to the Insurance Department so that insurance companies pay for programs such as Timothy's Law, the mandated coverage of mental health treatments.

Further, the governor also will propose a new tax on some physician services to raise $50 million.

The bottom line will be a net increase in costs that ultimately get paid by subscribers, thereby increasing the cost of coverage at a time that most upstate insurers are struggling.

Hospital cost saving initiatives will amount to $700 million next year and $50 million this year. Some of that will come from a 0.7 percent tax on gross receipts and Medicaid rate reductions. Graduate medical education funds will be redirected to save $141 million and another $23 million will be cut through reforming reimbursement.

Nursing homes will be cut by $4.2 million this year and $420 million next year. Home care will be cut $190 million next year.

A number of other public health programs will come with savings by, for instance, taxing non-diet sodas under an "obesity tax" that will raise $404 million. Prescription drug costs, a hit on pharmacies and drug makers, will cut by $111 million.

Among the reductions in education spending, public colleges will be directed to raise tuitions. But despite the cuts, Paterson will try to make it easier for SUNY schools to partner with private developers who want to build on campus property. The public/private initiative is seen as a way to stimulate construction of private housing for campus residents.

The Empire Zone program will be cut by at least 50 percent, saving the state tens of millions by not extending benefits as liberally.

The budget will come a day after Senate Republicans vote on a bill to stimulate the economy by phasing out the Empire Zone program through 2011 and using the savings as tax breaks for companies.

The governor has contemplated instituting a different pension system for new employees, but the so-called Tier 5 program may not make it to the budget. He is also expected to reiterate a call for greater health care payments from retirees and the closure of some juvenile detention facilities.

"The soda tax does not make much sense. There is ZERO evidence that people who stop drinking soda alone will lose weight. There is even some evidence (in animals) that the calorie free sodas with the artificial sweeteners actually cause weight gain."

- And if there was a study proving the soda/weight connection, how about we publicize the information instead of changing the tax code. My understanding is that there is a reverse correlation in that skinny people tend to drink the real soda and heavier people more likely tend to choose the diet version.

"How about taxes on political contributions? How about windfall profits taxes on the incomes of any politician above whatever it was before they took office?...How about a tax on all white men? ...How about a luxury tax on all cosmetic procedures?"

Very funny. It's all tempting. Tax everything we don't like when it's our turn to be in power. They tried the most obvious one - luxury tax on new yachts. It lasted about a minute. Turned out that most rich yachters already had a perfectly good boat and the Democrat leader of the Senate (Mitchell D-Maine) was from a yacht building state...

Call me old fashioned but how about we tax each dollar of income the same no matter the source and each dollar of consumption the same no matter the destination, i.e. equal treatment under the law. People might have a different view of demanding or tolerating free services if they didn't believe someone else was paying for it.

By SALLY C. PIPESPeople are policy. And now that President-elect Barack Obama has fielded his team of Tom Daschle as secretary of Health and Human Services and Melody Barnes as director of the White House Domestic Policy Council, we can predict both the strategy and substance of the new administration's health-care reform.

The prognosis is not good for patients, physicians or taxpayers. If Mr. Daschle meant what he wrote in his book "Critical: What We Can Do About the Health-Care Crisis," Americans can expect a quick, hard push to build more federal bureaucracy, impose price controls, restrict medicines and technology, boost taxes, mandate the purchase of health insurance, and expand government health care.

In his book, Mr. Daschle proposes a National Health Board to regulate the way health care is provided. This board would have vast powers in regulating the massive federal health-care system -- a system that includes Medicare, Medicaid, and other programs. Under Mr. Obama, it is likely that that system will be expanded and that new government insurance for the nonelderly, nonpoor will be created.

Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government. And because the government is such a big player in the health-care market (46% of health-care spending comes from the government), the board would effectively set parameters for private insurers.

It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized. The details of health-care policy may not be kitchen table conversation, but the fact that a Washington committee can deny grandma a hip replacement due to her age, or your sister a new and expensive drug, is. Health care is personal and voters will pressure lawmakers on access to care.

Liberal experts, Mr. Daschle included, believe that America needs to ration new technology and drugs. In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom's National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs. NICE's denial of care is legendary -- from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It's just that the bureaucrats don't consider them cost effective.

The Opinion Journal WidgetDownload Opinion Journal's widget and link to the most important editorials and op-eds of the day from your blog or Web page.Americans will not put up with such limits, nor will our elected representatives. Mr. Daschle himself proves this. He punts the hard decisions about rationing to an unelected board. Yet his main proposals are not only about expanding subsidized programs to cover more people but about adding the massively expensive benefit categories of mental health, which has a strong lobby behind it, and long-term care, which is important to the broad middle class.

One of the great myths in health care is that the uninsured are responsible for driving up private premiums by shifting costs. Uncompensated care certainly shifts some costs to private payers. Yet these costs are actually quite manageable in the aggregate, akin to what retailers lose due to shoplifting. The major cost shift is from government programs -- Medicare and Medicaid -- to private plans. The government pays doctors to treat Medicare and Medicaid patients. But the rates it pays, on average, are less than the cost for providing care to these patients. This is why Medicaid patients, and increasingly Medicare patients, struggle to find doctors. Putting more people on these programs will destabilize the remaining private system and create a coalition for price and wage controls.

Americans will never tolerate this. Remember our managed-care experiment in the 1990s. It succeeded in its main goal of controlling costs without an aggregate reduction in health quality. But in asking Americans to limit their choices, it prompted a bipartisan act of Congress to provide patients with a Bill of Rights. Now Mr. Daschle proposes nothing less than a giant HMO with a federal bureaucracy setting the benefit plan.

Mr. Daschle's model is Massachusetts. But Massachusetts's plan is an unfolding disaster and demonstrates how Mr. Daschle's private/public model is merely a stalking horse for government-dominated health care.

Samuel Huntington's Warning – Fouad AjamiWhy Detroit Has an Especially Bad Union Problem – Logan RobinsonObama Will Ration Your Health Care – Sally C. PipesThe FDA Is Killing Crohn's Patients – Gideon J. Sofer The headline claim is that the program has signed up 442,000 more people for health insurance. The reality is that 80,000 of these were simply put on Medicaid and 176,000 more on the taxpayer-subsidized plans. Costs have exploded, requiring additional tax hikes and the entire system is only possible due to sizable transfers from the federal government. The plans are so unaffordable that in 2007, 62,000 people were exempted from the individual mandate. So much for universal coverage.

The only way the Massachusetts plan will survive is with continued and increasing federal subsidies -- that is, tax revenue from the residents of other states. The only way Mr. Daschle's proposed plan would survive is with massive deficit spending -- that is, with taxpayer money from future Americans, many of whom are not yet born.

Mr. Daschle and the Democrats have spent years developing both the policy and political strategy to make the final push for taxpayer-financed universal health insurance. They have the players on the field, a crisis providing a sense of urgency, and a playbook filled with lessons learned from years of health policy reform disasters -- most recently that of HillaryCare in 1994.

The big questions for believers in private medicine are at this point political and strategic. With employers and most insurers reportedly on board with the new administration's desire for radical overhaul, who will step in to ask the tough questions? Will these issues get raised in time to provoke a meaningful, fact-based debate? Americans could easily find that Mr. Obama's 100-day honeymoon ends with a whole new health-care regime they hadn't quite bargained for.

Ms. Pipes, president and CEO of the Pacific Research Institute, is the author of "The Top Ten Myths of American Health Care: A Citizen's Guide" (Pacific Research Institute, 2008).

WASHINGTON, Jan. 8 -- Tom Daschle, picked by President-elect Barack Obama to be Health and Human Services secretary, said medical trainees should have school loans forgiven and receive other incentives to choose careers in primary care. Daschle told senators at his confirmation hearing today he wants to send a message to medical students: "If you take this route, we're going to find ways to ensure that you have the financial wherewithal to become that front-line provider that we need."

Senate approval is expected for the well-liked ex-senator from South Dakota. Republicans on the committee gave him a friendly reception at the hearing, and Orrin Hatch (R-Utah) announced he would support Daschle's nomination.

Daschle told the committee he has been laying the groundwork for a healthcare reform plan, which he said cannot be dictated from the White House and Congress.

He advocated a more grassroots approach and said he's taken ideas from Obama's transition Web site, which has received tens of thousands of comments, and from local community health forums in the last several months.

Daschle said the Centers for Medicare and Medicaid Services should save money by moving to a medical-home care model and steering its focus toward prevention and wellness rather than paying for disease treatment.

The CDC should better utilize community-based prevention efforts, like smoking cessation and weight loss programs, Daschle said. He said he would "revitalize" CDC's ability to detect and investigate health threats and focus on better coordination between public and private entities.

Daschle promised to restore trust in the FDA, citing a survey that found nearly two-thirds of Americans don't believe that the agency can ensure drug safety and effectiveness.

"Ensuring the food we eat and the medications we take are safe is a core protection that American people deserve and a core responsibility of government," Daschle said.

Daschle said all the agencies he would oversee need to operate with fewer political motivations.

"I want to reinstate a science-driven environment," he said. "I want to take politics out of it as much as possible and allow scientists to do their job."

Daschle said the National Institutes of Health budget is so limited that only 10% of grant applications are funded.

"I will work to strengthen NIH, with leadership that focuses on the dual objectives of addressing the healthcare challenges of our people and maintaining America's economic edge through innovation," he said.

Although the HELP committee traditionally holds confirmation hearings for the HHS post, the Finance Committee will hold its own hearing and have final say on whether to advance Daschle's nomination to the Senate floor. That hearing has not been scheduled yet.

The HELP committee's senior Republican Michael Enzi (R-Wyo.) said the last two HHS secretaries were confirmed within two weeks of their appearances before the HELP committee.

Daschle served three terms in the Senate and was minority leader from 2001 to 2004, when he lost a re-election bid. He joined the Center for American Progress, a Democratic think tank, as a senior fellow and has advised the lobbying firm Alston & Bird.

He published a book on health care in 2008, Critical: What We Can Do About the Health-Care System. Enzi said he had recommended it to all his staff.

Today's hearing was also notable for the appearances of Kennedy, who appeared healthy and fit despite his recent bout with malignant glioma, and Robert Dole, the former GOP senator from Kansas.

Daschle's wife was/is also a HUGE lobbyist so maybe 99% of the family income comes from lobbying? Makes Obama look a lot like Bill Clinton - say anything you want to any audience at any time and have enough charm to pull it off. It's not the lobbying; it's the obvious deception that disgusts me.

Not mentioned, Daschle was the ringleader of the blocking of appointments to the judiciary by the minority in the senate, so he went from winning re-election by 30 points to losing in his own state.

For those of us who want to see what's in store for US health care we should probably read Daschle's book. We are going down the road of gigantic federal control, expansion, redistribution, and subtle (politically covered) rationing. There will be a board which will oversee and control one seventh of our economy:

Visions for Change in U.S. Health Care — The Players and the Possibilities

John K. Iglehart

Under the incoming presidential administration, U.S. Democratic leaders are determined to achieve a long-elusive goal: securing "affordable, accessible health care for every single American," as President-elect Barack Obama put it recently. Recognizing the blunders that doomed the reform effort of President Bill Clinton 16 years ago, the new administration is working closely with Congress to craft a bill that will attract sufficient support to ensure enactment.

Although some critics argue that we can ill afford the costs of expanded coverage and other reforms with the economy in recession and an ever-growing federal deficit, Obama counters that these are pocketbook issues, integral to recovery efforts. At a December news conference, when he introduced Tom Daschle as his choice for secretary of Health and Human Services, Obama said a major health care initiative "has to be intimately woven into our overall economic recovery plan. It's not something that we can put off because we are in an emergency. This is part of the emergency."

The new administration's proposal for health care reform will not be part of the large stimulus package that Democratic legislators plan to enact in early January. Though the proposal is a work in progress, its central tenets are well known and, in some key respects, resemble the plan enacted in Massachusetts — which, in 2 years, has reduced the state's uninsured to 2.4% of its population (the lowest in the country), according to a 2008 report by the Urban Institute.

Obama's proposal would enable people with employer-sponsored health insurance coverage to retain it, if they prefer, and would require large employers either to offer their workers "meaningful coverage" or to contribute a certain percentage of their payroll to support a new public plan. The proposal would also create an insurance exchange through which people without employer coverage could select private coverage or the public plan at rates similar to those offered through large employers. Obama has pledged to "lower costs by taking on anticompetitive actions in the drug and insurance companies," to support disease prevention and health promotion efforts, and to invest $50 billion over the next 5 years to accelerate adoption of health information technology.1

A number of health-related items are being considered as elements of the early stimulus package, largely to prevent people who lose their jobs from losing their coverage and to begin investing in the infrastructure for a more efficient delivery system. These items include increased federal support to states to maintain or expand their Medicaid enrollment, reauthorization of and increased funding for the State Children's Health Insurance Program, grants to states to speed adoption of health information technology, and expansion of the Consolidated Omnibus Budget Reconciliation Act (COBRA) to give certain laid-off workers the right to temporarily continue insurance coverage at group rates.

Democrats' fortunes improved dramatically in November when Obama swept to a historic victory over Republican Senator John McCain. Thanks to the unpopularity of President George W. Bush and Obama's coattails, Democrats also increased their majorities in both houses of Congress — to margins of 257 to 178 in the House and 58 to 42 in the Senate (if Democrat Al Franken of Minnesota wins the seat), including two independents who caucus with the Democrats. (The retirement of Obama and Democrats Hillary Clinton and Ken Salazar from the Senate leaves open seats in Illinois, New York, and Colorado, and the race in Minnesota is undecided.) Republicans — if their caucus can maintain tight discipline — will still wield considerable influence in the Senate, where it takes 60 votes to overcome a filibuster.

Determined to avoid the mistakes that brought down the Clinton reform plan, Obama demonstrated in his early appointments the importance he attaches to maintaining close ties between Congress and the White House. He selected Rahm Emanuel, a powerful congressman from Illinois, as chief of staff, and former Senate Majority Leader Daschle as secretary of Health and Human Services and director of a new White House Office of Health Reform. Daschle has set out his own ideas for reform in a recent book, calling for all Americans to purchase coverage and for the creation of a federal health board (modeled after the Federal Reserve Board) that would have sweeping powers to mandate policies for all federal health programs.2 Peter Orszag was named Obama's director of the Office of Management and Budget, a powerful agency that prepares the government's annual budget. Since 2007, Orszag has been the director of the Congressional Budget Office, where he has placed a heavy emphasis on health-related issues.

Democratic congressional leaders will also play influential roles in promoting the administration's health reform agenda and urging Republican legislators to join as cosponsors. House Speaker Nancy Pelosi (D-CA) is a dominant figure who ranks health care reform among her highest priorities. Senate Majority Leader Harry Reid (D-NV) may have more difficulty maintaining discipline within his ranks because in the Senate there is disagreement on the shape reform should take. For example, Senators Ron Wyden (D-OR) and Robert Bennett (R-UT) have persuaded 15 other senators to cosponsor a bill that the authors assert reflects an "ideological truce" between the parties: "Democrats are correct in saying that universal coverage is necessary to fix health care," they write. "Republicans are correct in saying that market forces play an important role in health care by promoting competition and innovation. The Healthy Americans Act strikes a balance between these ideals."3

Five congressional committees will be instrumental in refining any reform plan. Three of Pelosi's California colleagues, all liberal Democrats, hold leadership positions on the three key House panels: Henry Waxman is the new chair of the House Energy and Commerce Committee, George Miller chairs the House Education and Labor Committee, and Pete Stark chairs the House Ways and Means Subcommittee on Health. The relevant Senate committees are the Finance Committee, chaired by Max Baucus (D-MT), and the Health, Education, Labor, and Pensions Committee, chaired by Edward Kennedy (D-MA).

The House Ways and Means Committee is generally considered the most influential panel in Congress because of a constitutional requirement stipulating that all tax legislation must originate there. It also oversees Medicare Part A (which covers hospitals), public welfare, Social Security, trade, and unemployment compensation. Although Representative Charles Rangel (D-NY) chairs the committee, he often defers to Stark on health issues, and his standing has been weakened by ethics problems currently under investigation. Stark recently told reporters that once reform legislation is introduced, consideration of it would probably consume most of 2009, with enactment possible in early 2010. Stark has long supported "Medicare for all" as his preferred approach to expanding coverage; he opposes privatizing the program. He was a lead sponsor of the Children's Health and Medicare Protection Act (CHAMP), a measure the House approved in August 2007 on a vote of 225 to 204 that would have replaced the formula on which Medicare's physician fees are set. The bill, which died in the Senate, would also have placed greater emphasis on primary care and preventive services covered by Medicare by allowing physician payments in these areas to grow at a rate 2.5% faster than that of the gross domestic product (GDP), whereas payments for all other physician services would be limited to the GDP's growth rate.

Waxman established a reputation as an adroit legislator during the 15 years he chaired the House Energy and Commerce Subcommittee on Health (1979 to 1994). His most significant legislative accomplishment during a period that included the presidency of the conservative Ronald Reagan was pressing Congress to vastly expand Medicaid.4 In recent weeks, Waxman demonstrated his political acumen by securing enough votes in the House Democratic caucus to wrest the chairmanship of the Energy and Commerce Committee from John Dingell (D-MI), who in February will become the longest-serving House member in history, with 53 years of service. The practical Waxman recently noted that the "best approach to reform is what we can pass . . . that secures the goal of universal coverage, sensible controls on cost, and assurance of quality care." But he also said he would work to bring generic versions of biologic products to the market and to restore the effectiveness of the Centers for Disease Control and Prevention and the Food and Drug Administration.

Baucus's Senate Finance Committee oversees Medicare, Medicaid, public welfare, Social Security, taxes, trade, and unemployment insurance. Baucus is a moderate who occasionally upsets his liberal colleagues by casting votes more reflective of Montana conservatism than his party's activism. In mid-2008, however, he came out strongly in favor of ambitious health care reform and has since released an 89-page "call to action" that embraces a commitment to strengthening the employer-based insurance system, bolstering the role of primary care, and reexamining Medicare's graduate medical education policies.5 Baucus also outlined an approach to reforming Medicare's physician payment system that resembles the model in CHAMP.

Senator Kennedy, for his part, is determined to top his many health policy accomplishments by winning enactment of universal coverage. In September, Kennedy, who is undergoing treatment for brain cancer, directed his staff to organize roundtable discussions among representatives of disparate interests (large and small businesses, community health organizations, consumers, health plans, hospitals, labor, physicians, and others) to identify issues on which there is broad agreement or conflicting opinion and strive to build support for reform. One purpose of these ongoing discussions is to neutralize opposition to the ambitious reform designs that Democrats hope to enact. One participant, Karen Ignagni, chief executive officer of America's Health Insurance Plans (the new incarnation of an organization that helped to bring down Clinton's reform plan with its devastating "Harry and Louise" ads), said of the roundtable: "You see a range of diverse stakeholders trying to work together to achieve health care reform."

Congressional Republicans have been slow to engage Democrats on health care issues. They have developed no alternative proposals, and no armies of grassroots supporters or well-financed private organizations seem poised to do battle against reform. This situation could change rapidly once proposals are introduced, hearings commence, and winners and losers are clearly identified. Republicans' greatest concerns seem to be the creation of a new public plan, which many fear is a backdoor approach to a single-payer system; the possible creation of a federal health board with sweeping new powers over benefit packages, which might stifle innovation; and the long-term financial implications of providing near-universal coverage.

President-elect Obama faces a daunting set of challenges as his grand vision for change comes into closer contact with the realities of U.S. politics. Obama has acknowledged that hundreds of billions of dollars will be added to the federal deficit as he pursues economic recovery, but he has also vowed to scour the budget in search of wasteful spending to offset these new costs. This exercise, in which Congress will undoubtedly participate, will provoke many a pitched battle and is certain to affect Americans' reaction to the new president's definition of "change."****

Source Information

Mr. Iglehart is a national correspondent for the Journal.

An interactive graphic on key players in health care reform is available at NEJM.org.

The House made its first down payment on President Obama's health-care plans last week, passing 289-139 a major expansion of the State Children's Health Insurance Program. The Senate is scheduled to take it up soon and pass it easily as well. These days tens of billions in new spending is a mere pittance, but Schip is also the Democratic model for a quantum jump in government health care down the line.

The bill became a liberal Pequot after President Bush repeatedly vetoed it in 2007 (while supporting a modest expansion). The GOP has no hope of stopping it now, so Schip will more than double in size with $73.3 billion in new spending over the next decade -- not counting a budget gimmick that hides the true cost. The program is supposed to help children from working-poor families who earn too much to qualify for Medicaid, but since it was created in 1997 Democrats have used it as a ratchet to grow the federal taxpayer share of health-care coverage.

With the new bill, Schip will be open to everyone up to 300% of the federal poverty level, or $63,081 for a family of four. In other words, a program supposedly targeted at low-income families has an eligibility ceiling higher than the U.S. median household income, which according to the Census Bureau is $50,233. Even the 300% figure isn't really a ceiling, given that states can get a government waiver to go even higher. Tom Daschle's folks at Health and Human Services will barely read the state paperwork before rubberstamping these expansions.

The political purpose behind Schip has always been to capture the middle class. Every time the program grows, it displaces private insurance. Even before Democrats struck down rules limiting crowd out, research indicated that for every 100 children signed up -- now more than 7.1 million -- there is a reduction in private coverage for 25 to 50 kids. Exactly the same thing will happen if Messrs. Obama and Daschle end up introducing a "public option," a government insurance program modeled after Medicare but open to anyone of any income. As with Schip, any net increase in insurance coverage will come by having taxpayers gradually supplant the private system.

Schip money is delivered as a block grant, which states are supposed to match, though national taxpayers end up paying 65% to 83% of the total cost. When states make health-care promises they can't afford -- such as New York, which expanded the program to 400% of poverty -- the feds always step in with, yes, a bailout. The House bill creates a "contingency fund" precisely for that purpose, and also allots bonus payments to states that boost Schip enrollment, so Governors will be further rewarded for overspending. All this is propped up by a permanent increase in the tobacco tax, which will rise to $1 a pack from the current 39 cents -- thus financing a permanent and growing entitlement with a declining corps of smokers.

Lately Mr. Obama has been making noises about the necessity of entitlement reform. This is no way to start.

The more we dig into the pile of spending and tax favors known as the "stimulus bill," the more amazing discoveries we make. Namely, Democrats have apparently decided that the way to gun the economy is to spend even more on health care.

This is notable because if there has been one truly bipartisan idea in Washington, it's that the U.S. as a whole spends too much on health care. President Obama has been talking up entitlement reform as a way to free up the money for his other social priorities. But it turns out that Congress is using the stimulus as cover for a massive expansion of federal entitlements.

Only the bill's $20 billion or so devoted to electronic health records can be reasonably called an investment. More typical is the $87 billion that will go to Medicaid, which -- silly us -- we underestimated by about $6 billion in our stimulus editorial yesterday. This pot of money will be used to blow out the federal matching rate by 4.9 percentage points across the board. Medicaid is nominally a joint state-federal program, but the feds pick up 57% of the Medicaid bill on average and are willing to go as high as 82% in some states. In other words, Democrats want to bail out the states that make unaffordable health-care promises and haven't tried to control costs. This latest rescue will give Governors more incentive to do so, given that the more they spend, the more Congress pays.

National taxpayers will also fund a new program allowing some laid-off workers receiving unemployment checks to enroll in Medicaid. For the first time ever on a large scale, the federal government will pay 100% of the costs they incur, and states are explicitly prohibited from means-testing this benefit. Supposedly the $11 billion plan will expire in 2010, but the word "temporary" does not exist in the entitlement world -- and Democrats will fight furiously to extend these benefits before they sunset.

Another damaging inspiration is the plan to throw $30.3 billion at Cobra insurance plans. The unemployed are currently allowed to keep their work health benefits for 18 or 36 months since 1986. While they search for a new job, they must pay 102% of the full insurance premium, including the employer's share. But Democrats now plan to subsidize these plans to the tune of 65%.

Are they making Cobra a new entitlement? Cobra was never intended as an option to assist the long-term unemployed -- considering that adverse selection means Cobra enrollees cost businesses about 145% as much as covered employees. Since Democrats want to boost participation by propping up Cobra use, that will result in less capital to invest in new jobs in the middle of a recession. It will also mean adding another disincentive (in addition to unemployment insurance) to get a new job. When you subsidize people not to work, you get more nonworkers.

Not for nothing did Democratic heath-care commissar Pete Stark tell the New York Times that "We accomplished more today than in the last eight years" after his committee approved the Medicaid and Cobra pieces of the stimulus. In one swoop Democrats will make employer-sponsored health care even more expensive and expand opportunities for an anxious public to join, or remain on, the welfare rolls. The pretext of "stimulus" is being leveraged to capture ever more of the private health-care market and transfer those costs onto government.

But don't forget that everyone agrees that health spending is already too high. So the stimulus also devotes $1.1 billion to create a new bureaucracy called the Federal Coordinating Council for Comparative Effectiveness Research. A billion dollars isn't nearly enough to conduct the rigorous clinical studies needed to provide more information on what medical treatments result in the best outcomes. But Democrats want to get this "health-care Fed" on the books now so it's around when they pass the next entitlement expansion -- for the entire middle class.

When government finances start to buckle under that subsidy, the comparative effectiveness outfit will start to ration care to control costs, much like the United Kingdom's National Institute for Clinical Excellence (NICE). The draft report accompanying the House portion of the bill notes that procedures and drugs "that are found to be less effective and in some cases, more expensive, will no longer be prescribed."

In sum, what we are really getting in this stimulus bill are several more steps in the gradual government takeover of the health-care market.

By NADEEM ESMAILPresident Obama and Congressional Democrats are inching the U.S. toward government-run health insurance. Last week's expansion of Schip -- the State Children's Health Insurance Program -- is a first step. Before proceeding further, here's a suggestion: Look at Canada's experience.

Martin KozlowskiHealth-care resources are not unlimited in any country, even rich ones like Canada and the U.S., and must be rationed either by price or time. When individuals bear no direct responsibility for paying for their care, as in Canada, that care is rationed by waiting.

Canadians often wait months or even years for necessary care. For some, the status quo has become so dire that they have turned to the courts for recourse. Several cases currently before provincial courts provide studies in what Americans could expect from government-run health insurance.

In Ontario, Lindsay McCreith was suffering from headaches and seizures yet faced a four and a half month wait for an MRI scan in January of 2006. Deciding that the wait was untenable, Mr. McCreith did what a lot of Canadians do: He went south, and paid for an MRI scan across the border in Buffalo. The MRI revealed a malignant brain tumor.

Ontario's government system still refused to provide timely treatment, offering instead a months-long wait for surgery. In the end, Mr. McCreith returned to Buffalo and paid for surgery that may have saved his life. He's challenging Ontario's government-run monopoly health-insurance system, claiming it violates the right to life and security of the person guaranteed by the Canadian Charter of Rights and Freedoms.

Shona Holmes, another Ontario court challenger, endured a similarly harrowing struggle. In March of 2005, Ms. Holmes began losing her vision and experienced headaches, anxiety attacks, extreme fatigue and weight gain. Despite an MRI scan showing a brain tumor, Ms. Holmes was told she would have to wait months to see a specialist. In June, her vision deteriorating rapidly, Ms. Holmes went to the Mayo Clinic in Arizona, where she found that immediate surgery was required to prevent permanent vision loss and potentially death. Again, the government system in Ontario required more appointments and more tests along with more wait times. Ms. Holmes returned to the Mayo Clinic and paid for her surgery.

On the other side of the country in Alberta, Bill Murray waited in pain for more than a year to see a specialist for his arthritic hip. The specialist recommended a "Birmingham" hip resurfacing surgery (a state-of-the-art procedure that gives better results than basic hip replacement) as the best medical option. But government bureaucrats determined that Mr. Murray, who was 57, was "too old" to enjoy the benefits of this procedure and said no. In the end, he was also denied the opportunity to pay for the procedure himself in Alberta. He's heading to court claiming a violation of Charter rights as well.

These constitutional challenges, along with one launched in British Columbia last month, share a common goal: to win Canadians the freedom to spend their own money to protect themselves from the inadequacies of the government health-insurance system.

The cases find their footing in a landmark ruling on Quebec health insurance in 2005. The Supreme Court of Canada found that Canadians suffer physically and psychologically while waiting for treatment in the public health-care system, and that the government monopoly on essential health services imposes a risk of death and irreparable harm. The Supreme Court ruled that Quebec's prohibition on private health insurance violates citizen rights as guaranteed by that province's Charter of Human Rights and Freedoms.

The experiences of these Canadians -- along with the untold stories of the 750,794 citizens waiting a median of 17.3 weeks from mandatory general-practitioner referrals to treatment in 2008 -- show how miserable things can get when government is put in charge of managing health insurance.

In the wake of the 2005 ruling, Canada's federal and provincial governments have tried unsuccessfully to fix the long wait times by introducing selective benchmarks and guarantees along with large increases in funding. The benchmarks and the guarantees aren't ambitious: four to eight weeks for radiation therapy; 16 to 26 weeks for cataract surgery; 26 weeks for hip and knee replacements and lower-urgency cardiac bypass surgery.

Canada's system comes at the cost of pain and suffering for patients who find themselves stuck on waiting lists with nowhere to go. Americans can only hope that Barack Obama heeds the lessons that can be learned from Canadian hardships.

Mr. Esmail, based in Calgary, is the director of Health System Performance Studies at The Fraser Institute.

Dashcle was felt to be in position with his influence peddling contacts and experience to be able to push through heatlh reform. Whether or not we would like his reforms is open to debate. For those who have no insurance they would likely be pleased. For those with existing medicare, they would likely get rationed care. And for those who pay for commercial insurance they would get screwed most likely. That said the system is broken and something has to change but what I don't know:

Losing Daschle Hurts, but Won't Kill Health PlansPosted Feb 3, 09 4:13 PM CST in Science & Health, Opinion, Politics (Newser) – The loss of Tom Daschle is a blow to President Obama’s plans for health-care reform, but the administration still has the resources to get the job done, Jonathan Cohn writes in the New Republic. Daschle was not only to head the Department of Health and Human Services, but also a White House office on health reform—which is where his political know-how would’ve come in handy.

“Daschle had a combination of talents not easy to find in one person,” Cohn writes. “But that doesn’t mean you can’t replace those skills, particularly if you’re willing to find several people instead of one.” While number of current or former governors could take over the cabinet position, Cohn pushes scholar Jeanne Lambrew for the reform office: “In fact, based on things I’ve heard, she’s been doing much of it for a while.”Source: New Republic

Tragically, no one from either party is objecting to the health provisions slipped in without discussion. These provisions reflect the handiwork of Tom Daschle, until recently the nominee to head the Health and Human Services Department.

Senators should read these provisions and vote against them because they are dangerous to your health. (Page numbers refer to H.R. 1 EH, pdf version).

The bill’s health rules will affect “every individual in the United States” (445, 454, 479). Your medical treatments will be tracked electronically by a federal system. Having electronic medical records at your fingertips, easily transferred to a hospital, is beneficial. It will help avoid duplicate tests and errors.

But the bill goes further. One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.”

Hospitals and doctors that are not “meaningful users” of the new system will face penalties. “Meaningful user” isn’t defined in the bill. That will be left to the HHS secretary, who will be empowered to impose “more stringent measures of meaningful use over time” (511, 518, 540-541)

What penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment? The vagueness is intentional. In his book, Daschle proposed an appointed body with vast powers to make the “tough” decisions elected politicians won’t make.

The stimulus bill does that, and calls it the Federal Coordinating Council for Comparative Effectiveness Research (190-192). The goal, Daschle’s book explained, is to slow the development and use of new medications and technologies because they are driving up costs. He praises Europeans for being more willing to accept “hopeless diagnoses” and “forgo experimental treatments,” and he chastises Americans for expecting too much from the health-care system.

Elderly Hardest Hit

Daschle says health-care reform “will not be pain free.” Seniors should be more accepting of the conditions that come with age instead of treating them. That means the elderly will bear the brunt.

Medicare now pays for treatments deemed safe and effective. The stimulus bill would change that and apply a cost- effectiveness standard set by the Federal Council (464).

The Federal Council is modeled after a U.K. board discussed in Daschle’s book. This board approves or rejects treatments using a formula that divides the cost of the treatment by the number of years the patient is likely to benefit. Treatments for younger patients are more often approved than treatments for diseases that affect the elderly, such as osteoporosis.

In 2006, a U.K. health board decreed that elderly patients with macular degeneration had to wait until they went blind in one eye before they could get a costly new drug to save the other eye. It took almost three years of public protests before the board reversed its decision.

Hidden Provisions

If the Obama administration’s economic stimulus bill passes the Senate in its current form, seniors in the U.S. will face similar rationing. Defenders of the system say that individuals benefit in younger years and sacrifice later.

The stimulus bill will affect every part of health care, from medical and nursing education, to how patients are treated and how much hospitals get paid. The bill allocates more funding for this bureaucracy than for the Army, Navy, Marines, and Air Force combined (90-92, 174-177, 181).

Hiding health legislation in a stimulus bill is intentional. Daschle supported the Clinton administration’s health-care overhaul in 1994, and attributed its failure to debate and delay. A year ago, Daschle wrote that the next president should act quickly before critics mount an opposition. “If that means attaching a health-care plan to the federal budget, so be it,” he said. “The issue is too important to be stalled by Senate protocol.”

More Scrutiny Needed

On Friday, President Obama called it “inexcusable and irresponsible” for senators to delay passing the stimulus bill. In truth, this bill needs more scrutiny.

The health-care industry is the largest employer in the U.S. It produces almost 17 percent of the nation’s gross domestic product. Yet the bill treats health care the way European governments do: as a cost problem instead of a growth industry. Imagine limiting growth and innovation in the electronics or auto industry during this downturn. This stimulus is dangerous to your health and the economy.

(Betsy McCaughey is former lieutenant governor of New York and is an adjunct senior fellow at the Hudson Institute. The opinions expressed are her own.)

What If ‘Comparative Effectiveness’ were applied to cheeseburgers?D.C. Examiner Op-EdBy: Sally C. Pipes2.6.2009

The Examiner (Washington, D.C.), February 6, 2009A shocking new provision was discovered today in the $825 billion stimulus package recently passed by the House of Representatives. Hidden half-way down page 538 is a clause that would provide $1.1 billion to help government bureaucrats compare the effectiveness of various cheeseburgers.

The provision was discovered by a congressional aide, who is also accusing his boss of torture for making him read the 647-page bill in its entirety.

As it turns out, the language of the “cheeseburger effectiveness” clause is virtually identical to a better-known provision in the bill that applies to medicine. The only apparent difference between the two clauses is that one uses the word “cheeseburgers” throughout, whereas the other uses terms like “medical treatments.”

“Many restaurants routinely pressure consumers into ordering a more expensive newfangled burger, even when it doesn’t represent a clear improvement in flavor over previous burgers."

Rep. Busybody insists that his cheeseburger effectiveness provision will solve this crisis – just as the comparative effectiveness provision will help solve the healthcare crisis.

“There are too many burgers on the market. Patrons are confused by all the choices out there,” he says. “They anguish over whether they should order a Big Mac or a Whopper. Soon after my law is passed, there will be only one burger on all fast-food menus. It will be made from tofu and taste horrible, so people will probably just eat tacos instead.”

Under the new program, government researchers will be charged with testing new sandwiches in three classes – chicken, fish, and beef – before they hit the marketplace. They'll check for such features as flavor, texture, general aesthetic appeal, possible side-effects, and nutritional value. Tacos will be exempt from all testing.

Fast-food restaurants worry the government-funded research will put billions of dollars from the sales of their newest and most lucrative sandwiches in jeopardy. They fear the research will be followed by regulation that would ban most cheeseburgers from the market as part of a congressional effort to lower overall food costs.

Rep. Busybody says their fears are warranted. His staff is currently working on follow-up legislation that would ban the three most problematic types of burgers:

1) ‘Me-too’ burgers, which have fancy names, but are no better tasting than other cheeseburgers already on the market;

2) Marginally-improved burgers, like the Triple-Decker, which costs a dollar more than the Double Quarter Pounder, but is only slightly more satisfying;

3) Frequently ineffective burgers, like the Fish-and-Pickles, which some people love, but many find disgusting.

Many in Congress have already come out in support of the cheeseburger measure within just hours of its discovery.

“If comparative effectiveness research can save the country money for medicine, then why not apply it to cheeseburgers, as well?” says Rep. Stanley Toetheline, who last week paid $200,000 in backtaxes upon his nomination to the House Ethics Committee.

Some consumers disagree. “Most days I order a Chicken Cheddar. But sometimes I want a Biggie Bacon,” says Joe Hartattak, a fork-lift operator from Kansas who eats fast food five times a week. “Some of my friends prefer the Double Trouble. We’re all different – so choice is important to us.”

Rep. Busybody disagrees. “People like Hartattak are just country bumpkins – the kind of fools who actually pay their taxes. They need smart government bureaucrats – people like me – to micromanage their lives.”

Other supporters say the research will help protect consumers like Hartattak from buying cheeseburgers that may not be worth the extra money.

Federal officials are already exploring a scheme to make findings from the studies binding by prohibiting “Travel & Entertainment” tax deductions for the purchase of unapproved burgers.

"If we're to get profiteering burger-companies under control, this comparative-effectiveness research effort has to have some teeth," says the administration’s newly appointed Burger Czar Ron Machater. "The tax penalty will ensure that restaurants can't rip off consumers with overpriced products.”

Backers of the research provision say restaurants don't have the incentive to compare their burgers with those of competitors. "Consumers are in the dark when it comes to figuring out which burger tastes best. Clearly, only the government has the resources and objectivity necessary to make an effective selection between the Big Mac and the Whopper,” says Machater, who admits to being a vegetarian.

In fact, Machater believes that fast-food television commercials – also known as “direct-to-burger-eater advertising” – should be banned altogether. “These ads hypnotize unsuspecting couch-potatoes into making late-night trips to White Castle.”

The burger effectiveness legislation is modeled after Britain’s National Institute for Health and Clinical Effectiveness (NICE) – an agency that evaluates medical treatments and then decides which ones the British health care system will cover.

Critics argue that in its zeal to save money, NICE often denies patients access to life-saving medicines. Last year, for example, NICE was widely criticized after it announced that four breakthrough drugs would not be covered for people with kidney cancer. As of today, only one of those drugs has been approved and it was just recently. Not surprisingly, Britain dramatically trails the United States in cancer survival rates.

Rep. Busybody says that Britain’s nightmare experience with “comparative effectiveness” doesn’t worry him. “Just because this model has been an abject failure in Britain doesn’t mean it won’t work here,” he says. “We’re on untrodden territory here – no one has ever tried this with cheeseburgers before.”Sally C. Pipes is president and ceo of the Pacific Research Institute. She is the author of The Top Ten Myths of American Health Care: A Citizen’s Guide.

***One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446).***

Well yes. Of course. Electronic medical records will also be used to store, centralize data, and have all this at the government's fingertips to so they can find ways to reduce costs by rationing care.

Nurses will replace doctors by simply following algorithms, cheaper and sometimes less effective drugs will be preferred, more services will not be paid as deemed inappropiate, patients will be forced to do preventative care (with financial incentives) and maybe even their habits, such as cigarettes, diets, exercise patterns will be tracked and their rates adjusted "accordingly".

I don't like it. But the system is totally out of control. Without some form of rationed care we will go bankrupt.

I believe the best hope is actually the pharmaceutical industry to find drugs that actually work to combat obesity and cancer and arthiritis that keeps as healthier and only in that way can we get what we want. Otherwise its rationed care or we all go bankrupt.

Offering health care to illegals doesn't help but that is probably only a small part of the problem.

Well, tragically it certainly looks to be going that way. The present system slandered as being free market, is actually bureaucratic madness. We of free minds and free markets need to make the case.====================Scott Grannis

Stealth Healthcare in the stimulus bill Tom Daschle didn't make it to the HHS post, thanks to being a tax cheat, but he has left us his legacy in the form of significant legislation buried in the new stimulus bill. Read all about it here if you haven't already. It boils down to creating a new national medical database that will keep track of everyone's medical records, so that eventually a National Coordinator of Health Information Technology can ration healthcare.

Any effort by the government to implement something like single-payer or universal healthcare will inevitably result in rationing and shortages. That's just simple economics: if people don't have to pay for their own health care, costs will rise, health care services will be in short supply, and the whole system will become inefficient. To wish it would happen otherwise is fanciful.

The urge to move us to universal healthcare is based on the belief that a modern, advanced society has an obligation to ensure that everyone receives healthcare treatment; it would be unconscionable to deny anyone treatment. Well, consider what would happen if we felt the same way about food: surely no one should be allowed to starve in this age of abundance ...

If the government paid for everyone's food, imagine the consequences. Filet mignon would fly off the shelves; home refrigerators would be stocked to capacity, spoiled food routinely chucked in the trash can; competition to produce better and cheaper products would become a quaint vestige of the past; hamburger meat would pile up; food quality would decline; complaints would skyrocket. It wouldn't take long before the government created an entire bureacracy to monitor and "regulate" prices. Any mistakes in setting prices would resort in shortages or abundancies. Sound familiar?

***Well, consider what would happen if we felt the same way about food:***

Well the Dems have already decided that owning a home is an entitlement. Thanks to them and the Republicans that were afraid to stand up to them because essentially they are the minority party in the US today and were afraid of upsetting those who would benefit from the give aways, we are going broke.

It is happening with health care. It is the most massive social engineering we have ever seen. And the Dems keep increasing their constituent base that would benefit from this and would love to have the minority who pay for it continue to do so and to an even larger extant.

Michelle BO is ashamed of our country. So I guess now she can be proud that we are turning to socialism.That's what she and BO wanted all along. Even with all their constituancies they are only getting it because of the impending collapse of the economy. That is remarkable to me. That most Americans still would not support them if it were not for the crash of banks.

The "stimulus" is the bill that keeps on giving, not least for journalists. Health-care providers and patients may have a different reaction, however, when they learn that Democrats are using the bill to create a health information monopoly that will help centralize government control of the health-care market.

In theory, electronic medical records are among the few stimulus ideas that might do some actual good. Democrats and Republicans agree that exchanging the paper files we mostly use now for digital versions will lower costs, cut down on medical errors, and maybe cure the common cold.

The Opinion Journal WidgetDownload Opinion Journal's widget and link to the most important editorials and op-eds of the day from your blog or Web page.Both the House and Senate stimulus bills include about $20 billion in incentive payments (mainly through Medicare and Medicaid) to encourage the digitization of medical records. Fair enough. But one of the reasons only an estimated 17% to 29% of doctors use health IT is because there are still many technical issues to work out. Different systems must be compatible so doctors can communicate with each other, coordinate care and share information -- and they don't want to invest in a platform that could become as obsolete as HD-DVD.

Democrats have decided that the way to jump this gap is for government simply to pick the next Blu-Ray. Instead of building on a voluntary public-private standard-setting body created by the Bush Administration, the stimulus bill codifies it as a federal office and gives it broad new powers if private companies are not "substantially and adequately" meeting the needs of doctors and hospitals. The health IT outfit will soon be deciding which platforms are up to code and shutting down competitors.

This will certainly muffle innovation, given that high-school dropouts have been known to scam U.S. health bureaucrats out of millions of dollars that should be preventable with off-the-shelf auditing software. Anyway, what's the rush? Democrats give the game away by mandating that most medical providers who aren't linked into the government-approved health information network after 2016 will start to be penalized. Their real political goal is to make a down payment on national health care.

The stimulus actually makes it harder for doctors, hospitals and pharmacies to use health IT, under the guise of "privacy." This is especially dishonest. Insurers already know the health condition of millions of Americans from claims information, which list diagnoses, prescriptions, procedures, etc. The government does too, because it pays so many medical bills through the entitlement programs.

In its pure form, the primary purpose of health IT is to organize all this data in a useful way, so we can get a better sense of health trends and outcomes. Large insurers like Kaiser Permanente and others are starting to do just that on their own, as well as creating the data-based tools that could give consumers a better value for their health dollars. The plug could get pulled from such efforts because the faux privacy provisions are so onerous.

The true political goal is cost control. For the Pete Stark Democrats whose ambition is Medicare for all -- no exceptions -- giving government exclusive control over electronic health information and reporting is a step toward "comparative effectiveness" research. That in turn will be used to impose price controls and deny some types of medical treatment and drugs. And because government is able to skew the whole health system through Medicare and Medicaid, comparative effectiveness could end up micromanaging the practice of medicine.

If three Republican Senators are going to help pass this stimulus, the least they can do is demand that this stalking horse for government-run health care is out. We need to debate this in the open, not slip it into legislation under false cover.

This piece can be read on several levels. With the specter of comparative effectiveness buried in the "stimulus" package looming, the politicization of health care standards is bound to follow, as demonstrated below. Combined with the pathological science trail blazed by global warming zealots, there are a lot of avenues open for politics guised as science to be inserted into all our lives.

Science, Politics, and ValuesThe Politicization of Professional Practice Guidelines

The Infectious Diseases Society of America (IDSA) issued updated clinical practice guidelines in 2006 for the diagnosis and treatment of Lyme disease.1 Within days, the Connecticut attorney general launched an investigation, alleging IDSA had violated state antitrust law by recommending against the use of long-term antibiotics to treat "chronic Lyme disease (CLD)," a label applied by advocates to a variety of nonspecific symptoms for which frequently no evidence suggests the etiologic agent of Lyme disease is responsible. The IDSA was forced to settle the claim to avoid exorbitant litigation costs, even though the society's guidelines were based on sound science. The case exemplifies the politicization of health policy, with elected officials advocating for health policies against the weight of scientific evidence.

The Antitrust Investigation of IDSA

Although untreated or inadequately treated Lyme disease can progress to cause neurological complications and arthritis, there is no evidence the disease has a chronic form (except perhaps as sequelae) in the absence of objective clinical or serological evidence of active infection.2 Nevertheless, some patient groups and a small minority of physicians contend Borrelia burgdorferi, the causative agent of Lyme disease, commonly persists in patients after standard antibiotic treatments. They maintain that a constellation of nonspecific symptoms such as fatigue, myalgia, headaches, and chest pain are evidence of chronic infection, and that standard diagnostics are inaccurate.3 Furthermore, some recommend using long-term, high-dose antibiotics—frequently administered intravenously—to treat patients with nonspecific symptoms and no objective evidence of infection.3

The IDSA treatment guidelines strongly disagreed and instead labeled the constellation of symptoms "post-Lyme syndrome"—either sequelae without ongoing infection or unrelated to B burgdorferi. The guidelines state, "There is no convincing biologic evidence for the existence of symptomatic chronic B burgdorferi infection among patients after receipt of recommended treatment regimens for Lyme disease. Antibiotic therapy has not proven to be useful and is not recommended for patients with chronic (6 months) subjective symptoms after recommended treatment regimens for Lyme disease."1 The IDSA guidelines also rejected the use of a variety of alternative diagnostic tests deemed unvalidated by the Centers for Disease Control and Prevention (CDC) and US Food and Drug Administration.

IDSA's guidelines were based on the biological implausibility of B burgdorferi persistence after proper treatment in the absence of objective indications of treatment failure; the high background rates of the subjective symptoms often attributed to chronic Lyme infection; and the absence of benefit from, and the serious adverse effects of, long-term treatment. The CDC4 and National Institutes of Health5 concurred in the judgment that long-term antibiotic use is not justified: "despite extensive study, no clear evidence has emerged to support the contention that CLD results from a past or persistent Lyme disease infection."5 American Academy of Neurology treatment guidelines for Lyme disease affecting the nervous system reached the same conclusion.6

The International Lyme and Associated Diseases Society (ILADS), a CLD advocacy group, immediately protested and asserted the superiority of its alternative guidelines,3 which others have suggested were based on substandard review methods.7 Shortly after, Connecticut Attorney General Richard Blumenthal launched an investigation of IDSA's guideline writing process, alleging it violated state antitrust laws by excluding differing viewpoints from its guideline creation process and including members who had financial interests in, or ties to, Lyme diagnostic and treatment makers.8 IDSA did disclose its panel members' potential conflicts of interest in its published guidelines, even though there is no evidence that any conflicts altered the guidelines' content. Meanwhile, the committee that created the ILADS guidelines included the president of a company that manufactures an alternative Lyme disease diagnostic test9 and multiple physicians whose practices are listed with a CLD advocacy group's patient referral service10—but ILADS did not disclose the conflicts in its guideline document.3

Antitrust laws are designed to ensure legitimate commercial competition and protect against predatory corporate practices due to inappropriate restraints on trade. Professional organizations, such as IDSA, can violate antitrust laws if their standard-setting is an unreasonable attempt to advance their members' economic interests by suppressing competition.11 Applying the antitrust "rule of reason," a challenger must show that the professional organization both possesses substantial market power and that the anticompetitive effects of its standards outweigh patient benefits.12 Even assuming IDSA wielded sufficient market power through its nonbinding guidelines to meet the first part (which is questionable considering that insurers and clinicians can independently choose which treatments to cover and prescribe), the second part of the rule of reason cannot be met because IDSA guidelines substantially advanced patients' interests.

The courts should defer to professional medical associations when standards are set on the basis of valid science aimed at protecting patient health or safety. A precisely on-point federal case (though one that does not bind Connecticut courts interpreting the state antitrust law) upheld the American Academy of Ophthalmology guidelines attaching the label "experimental" to radial keratotomy, a surgical procedure for correcting nearsightedness.13 "Antitrust law is about consumers' welfare," said the court, so ultimately professional guidelines are a "medical not a legal question."13 That truism should decide antitrust cases, so that when a professional organization bases its work on the weight of science there can be no improper restraint of trade.

After spending more than a quarter of a million dollars on legal expenses, IDSA agreed to settle with the attorney general (without admitting any fault), assenting to an ombudsmen-reviewed panel to assess the 2006 guidelines.14 While it is unlikely IDSA's guidelines will change due to the investigation, the daunting potential for litigation by those unhappy with the outcomes of treatment guidelines may well chill the willingness of medical associations to make appropriate scientific evaluations of controversial topics—a development that would significantly threaten patient care and increase medical costs.

Science, Values, and Politics

At the heart of this controversy is the conflict between the positive nature of science and the normative function of value systems and political thought. Science is, and can only be, descriptive and explanatory. Whether a scientific finding is judged to be accurate is dependent on the quality and rigor of the methods used and whether that finding is replicable. The scientific process is not democratic—no amount of desire for different results can establish them—and inconsistent findings create true controversy only when their methods are of comparable validity.

At the same time, the sciences cannot be normative. They can establish context and a factual base for normative discourse, but scientific findings cannot entail any particular normative conclusion without reference to outside systems of thought. Science, for example, cannot resolve the never-ending debate over abortion in the United States. Medical science can describe the maternal health risks of pregnancy, elucidate fetal development, and establish risks of birth defects and complications. Nothing, however, inherently follows from any of these; rather, policy makers must look outside science, to moral, religious, ethical, and legal norms—eg, when aggregated cells become human life or what the relationship between citizens and their government should be. Medical science can, and should, inform these discussions, and in a vibrant and healthy society, such value questions will be vigorously debated.

However, all too often, the normative and positive blend into one another. Positive assertions are presented in a normative light—for example, that the cost of treating a condition surpasses a benchmark of cost-effectiveness, hence it should not be used. This really consists of 3 separate assertions: the cost of treatment equals a particular amount (a positive claim); treatments costing more than a certain amount are not cost-effective; and cost-effectiveness should guide the allocation of health care resources. All these claims may be justifiable, but only the first can be established through scientific methods.

The converse—when normative views are passed off as positive assertions—is even more problematic, such as the well-documented issue of abortion and breast cancer in the Bush administration. Multiple adequately powered and well-designed and analyzed studies investigated the putative association between abortion and breast cancer and found no evidence of its existence. However, from 2002 to 2003, information was placed on the National Cancer Institute Web site suggesting a link between abortion and breast cancer, based largely on older epidemiologic studies that failed to sufficiently control for recall bias.15

The Connecticut attorney general's action against IDSA falls into this latter category. The CLD advocacy community understandably seeks answers for the symptoms attributed to Lyme disease. But when high-quality research repeatedly was inconsistent with the group's hypotheses, the community should have sought other answers. Instead, many advocacy organizations—and the attorney general—insisted (against the weight of evidence) on a link between the symptoms and chronic infection and continued to call for long-term antibiotic treatments. Even this was perhaps defensible—after all, medical studies cannot prove the nonexistence of a phenomenon—although physicians in the CLD community should treat their patients based on the best-available evidence. But when political leaders using the force of law sued IDSA for its appropriate scientific conclusions that differed with the results they desired, they abused the public good.

A wall of separation is needed between science, norms, and politics. Science should inform normative discussions and provide the evidentiary base for political choices. Likewise, values will always be important in deciding how science is applied for human benefit. But neither should be permitted to distort the other—limits on the outer boundaries of what questions each can answer must be respected when making public policy. Medical science, and the health of patients who depend on it, are too important to be subjected to political ideologies.

There is simply no way to provide health care to 48 million more people without taking money or benefits from those who already do have paid coverage

How is the 634 billion health care proposal going to be funded?

Much of the money is to be generated from squeezing private insurers who are in the Medicare Advantage program. They now get more than Medicare alone pays but will soon get no more than 100% thus to make money they will have to cut costs more than Medicare. This will no doubt result in less benefits, more costs to patients, and much more controlled care. If yo think your HMO is controlling you now this will be child's play to what we will see.

The smaller players will fail. There will be consolidation and the around 15 big players who provide around 70% of it now may stop providing this service to Medicare recipients altogether. More Hospitals will go out of business. Most are in the red now anyway.Most physicians will already get further squeezed more than they already are. As a primary care physician I am one of the few that may get a pitance more (5% is tossed about). But the big BO gov. will simply find another way to get it back somewhere else so this essentially meaningless raise is just that.

But the budget Obama proposed Thursday is not a finished blueprint for overhauling health care. Rather it's the opening bid in a tough negotiation. Anybody who's been in a bargaining session knows you never end up with your opening bid.

Obama is asking Congress: If you're going to cover an estimated 48 million uninsured Americans in the world's costliest medical system, how do you pay for it?

Obama's plan would set aside $634 billion over 10 years in a major effort to cover all Americans — a goal that could cost more than $1 trillion. Half the money would come from tax increases on upper-income earners; the other half from cuts to Medicare and Medicaid. Private insurance plans serving Medicare seniors would take the biggest hit, but hospitals, drug companies and home health agencies also face cuts.

Republicans and fiscally conservative Democrats are sure to disagree with Obama's specifics, but they may quietly applaud his determination to pay for health care reform, instead of adding to the deficit.

"This is a serious effort to get the process moving," said Mark McClellan, a doctor and health economist who ran Medicare for former President George W. Bush. "The specific financing proposals are going to have a very tough time."

Obama's approach is a conscious departure from the path former President Bill Clinton took in the 1990s. Clinton's 1,300-page health care bill tried to answer every question and ultimately went nowhere. Obama is asking Congress to fill in the blanks.

"He's outlining these cuts as examples of places where savings can be accrued," said Christine Ferguson, a health policy professor at George Washington University. "You put those on the table, and if people want to have this discussion, they have to propose alternatives."

Whether that dialogue succeeds depends not just on Obama, but on Congress and interest groups representing insurers and doctors, hospitals and drug companies, consumers and small business.

Clinton's top priority was to get everybody covered quickly. Obama has framed the problem differently, focusing on how to slow rising costs, so that everybody can eventually be covered.

"What the president is doing is bold, but it's not overreaching," said economist Robert Reischauer, president of the Urban Institute research center. "The administration is coming to grips with the reality that this will cost a lot of money, and it's committed to paying for it."

The tricky part is in the details.

For example, more than half of Obama's spending cuts would come from Medicare managed care plans. The private plans cost the government 14 percent more on average than care for seniors in traditional Medicare. That translates into lower out-of-pocket costs for seniors, who in a bad economy have been flocking to the plans, increasing enrollment to about 10 million.

"People are flooding into the program," said Dan Mendelson, president of Avalere Health, an information company serving government and the health care industry. "I don't think cuts of this magnitude ultimately are going to be palatable to Congress."

Obama would replace the current payments with a competitive bidding system estimated to save $177 billion over 10 years. That sent insurance company shares skidding Thursday on Wall Street. But some market analysts said there may be a silver lining: While competitive bidding could decrease profit margins, it might generate higher revenues for insurers if seniors keep signing up.

[the Obama plan] "will no doubt result in less benefits, more costs to patients, and much more controlled care."

Costs paid directly by the consumer and prices yielded directly to the producer comprise the mechanism that allocates resources the most efficiently. But the more crucial the market, the more we try to use inferior mechanisms to allocate the resources. In the 1990's the WSJ published an unbelievably complicated flow diagram of how healthcare decisions would be made, almost cartoon-like, taken from the literal text of the Hillary-care proposal. Congressional staffers and mid-level bureaucrats will be making very important decisions for people they never met.----Scott G wrote this week: "we could probably solve 80-90% of the healthcare problem by simply changing the tax code so that anyone, not just employers, could deduct the cost of healthcare insurance. This would reintroduce basic market dynamics to the healthcare market, and that is the only thing that can make healthcare cost-effective and widely available."

***Congressional staffers and mid-level bureaucrats will be making very important decisions for people they never met.***

They will be getting their advice from ivory tower New England liberal health care policy types a few are MDs and most are phDs who write the flow charts and policies with the idea of providing as much universal coverage in a cost effective way. They are looking at populations, and budgets, not individuals. These people are from Harvard Yale the usual know it all suspects.

Perhaps I should have posted under "Cognitive Dissonance" this piece that records Michelle Obama's role in, ah, redirecting, poor patients from the hospital where she was an administrator:

March 02, 2009Michelle Obama's Patient-Dumping Scheme

By David CatronThe First Lady helped create a notorious program that dumped poor patients on community hospitals, yet the national media ignore the story. Imagine if her husband were a Republican.

The University of Chicago Medical Center has received a good deal of justly opprobrious press over its policy of "redirecting" low-income patients to community hospitals while reserving its own beds for well-heeled patients requiring highly profitable procedures. Substantial coverage was given to a recent indictment of the program by the American College of Emergency Physicians. ACEP's president, Dr. Nick Jouriles, released a statement suggesting that the initiative comes "dangerously close to ‘patient dumping,' a practice made illegal by the Emergency Medical Labor and Treatment Act, and reflected an effort to ‘cherry pick' wealthy patients over poor."

Oddly absent from most of the unflattering press coverage of UCMC's patient-dumping scheme is any mention of the role our new First Lady played in devising the program. A laudable exception has been the Chicago Sun-Times, which reported last August that "Michelle Obama -- currently on unpaid leave from her $317,000-a-year job as a vice president of the prestigious hospital -- helped create the program."

On the rare occasions when other "news" media have bothered to connect the Urban Health Initiative to its glamorous creator, they have attempted to whitewash this tawdry program. Typical of such disingenuous coverage was a story in the Washington Post, which described it as "an innovative program to steer the patients to existing neighborhood clinics."

But no amount of journalistic lipstick can hide the reality that Mrs. Obama's initiative is a patient-dumping scheme. Such "cherry-picking," as Dr. Jouriles accurately describes it, was, at one time, fairly common. Prestigious institutions like the University of Chicago Medical Center routinely "dumped" Medicaid, uninsured and other unprofitable patients on less mercenary community hospitals. Many patients suffered needlessly, and more than a few actually died, as the result of this practice. So, in 1986, President Reagan signed the Emergency Medical Labor and Treatment Act (EMTALA) into law. EMTALA made such "redirection" illegal, but many high profile hospitals still chafed at being forced to treat poor patients. Enter Michelle Obama, UCMC's "Vice President for Community and External Affairs."

Mrs. Obama first hatched the UCMC program as the "South Side Health Collaborative," which featured a gang of "counselors" whose job it was to "advise" low-income patients that they would be better off at other hospitals and clinics. The program was so successful in getting rid of unwanted patients that she expanded it, gave it a new name, and hired none other than David Axelrod to sell the program to the public. According to the Sun-Times, "Obama's wife and Valerie Jarrett, an Obama friend and adviser who chairs the medical center's board, backed the Axelrod firm's hiring." Axelrod helped the future First Lady formulate a public relations campaign in which the "Urban Health Initiative" was represented as a boon to the community actuated by the purest of altruistic motives.

The resultant PR campaign was a study in Orwellian audacity. Chicago's inner city residents soon began hearing that UCMC's patient dumping program would "dramatically improve health care for thousands of South Side residents" and that the medical center was generously willing to provide "a ride on a shuttle bus to other centers." Likewise, the people who ran the community hospitals to which these unwanted patients were being shuttled began to read claims in local media to the effect that the Urban Health Initiative was good for them as well. Dr. Eric Whitaker, the Blagojevich crony who succeeded Mrs. Obama as Director of the program, repeatedly assured gullible reporters that the financial impact on these hospitals would be positive: "The initiative actually is improving their bottom lines." The CFOs of those hospitals were no doubt relieved to learn that treating Medicaid and uninsured patients is profitable.

But you just can't please some people. In one of the few frank passages of the Post article, we discover that many members of UCMC's medical staff believe the program is nothing more than an "attempt to ensure that the hospital retains only affluent patients with insurance." And another association of emergency physicians has joined ACEP in denouncing the Urban Health Initiative. The Chicago Tribune reports that Dr. Larry Weiss, president of the American Academy of Emergency Medicine is unhappy about UCMC's failure to consult its own ER physicians before initiating the program: "Not including emergency-room physicians ... would be analogous to changing the way surgery is performed in an operating room without involving any surgeons." Dr. Whitaker assures us, however, that such critics are merely "opposed to change."

Presumably, he would be similarly dismissive of Angela Adams, who brought her son to the medical center's ER after his lip had been partially torn off by a pit bull. As the Tribune puts it, "Instead of rushing Dontae into surgery ... the hospital's staff began pressing her about insurance." Unfortunately for Dontae, he was covered by Medicaid. So, all he got from the UCMC emergency department was a shot, some antibiotics, and instructions to "follow up with Cook County." Angela had to take her son across town to John Stroger Hospital, where he was immediately admitted for reconstructive surgery. Like doctors Jouriles and Weiss, Angela is having trouble seeing the community benefit of the Urban Health Initiative.

Meanwhile, the program's parents, Michelle Obama and David Axelrod, have moved to Washington. As the First Lady and the President's closest advisor, they wield enormous power. Indeed, they may be the most powerful people in the Obama Administration, aside from the President himself. If these two characters were willing to betray their Chicago neighbors -- the South Side's most vulnerable citizens -- with a disgraceful program like the Urban Health Initiative, what sort of mischief will they devise for the hapless denizens of flyover country?

Come to think of it, isn't Obamacare being sold to us in pretty much the same way the Urban Health Initiative was sold to Chicago?

David Catron is a health care finance professional who has spent more than twenty years working for and advising hospitals and medical practices. He blogs at Health Care BS.

By Carol PeracchioFor the past two years I have been employed in nursing as a medical record reviewer. I've reviewed hundreds of records, the old fashioned handwritten kind, and also the electronic medical record (EMR).

I am not ideologically opposed to EMRs. When done well, they are much more efficient and easier to read and use. However, it can take months to train an office in EMRs. And if the computers are down, everything stops. But overall, EMRs are a net plus. No, what I'm opposed to is Obama's plan to set up a Ministry of Health Information. In Obama's stimulus bill recently signed into law are provisions that will allow Washington unfettered access to every American's health history through the magic known as the EMR.

When I hear Obama and his spokesmen giving us the hard sell about EMRs I am reminded of the Sham-Wow® pitchman. EMRs will cure everything wrong with our health care! Watch as EMRs tackle that long wait to see your doctor! Now you're whisked into the exam room in ten seconds or less! High deductibles your problem? Not with EMRs! Our computerized records will cut overhead by 50%! Are you getting this, Camera Guy?

The problem with their sales pitch is it isn't convincing. After all, no one in the Obama administration has any experience with EMRs or in taking care of sick people. Like many non-medical people, Obama apparently envisions American health care like the television program Gray's Anatomy: chock full of gorgeous physicians who push the gurneys themselves and come up with exotic diagnoses based on high tech data. Every patient is teetering on the edge of calamity. Thank God the EMR has Mr. Patient's every burp recorded and at Dr. McDreamy's fingertips. Otherwise he'll never be able to make the life-saving diagnosis of Mrs. Jane Doe by commercial!

In reality, the vast majority of patients have dull ailments like bursitis and pneumonia. They see the doctor for their diabetes and the surgeon to get their gall bladder out. Most of us see the same doctor for years. If we move, Dr. New's office gets our records from Dr. Old's office. Most people would be stunned to find out how quickly an experienced physician can get "up to speed" on a new patient. We like to think we're complicated, fascinating cases. Most of the time, we're pretty boring.

"But what if the patient is unconscious or otherwise unable to communicate? Won't having everyone's health records in a central location help in that instance?" the Obama team will ask.

This situation does occur. People who take daily medications should carry a list with them. Those who have chronic illnesses or allergies should have medic-alert bracelets. There are solutions to this rare occurrence besides placing 300 million people's medical records in the hands of ACORN Health Information Management.

I recently heard an expert on television claim that gathering everyone's EMRs on one big government server will solve that sterotypical problem -- the doctor with indecipherable handwriting. I have to agree that some of these doctors must be writing with their feet. However, I employed a much simpler remedy than taking steps toward socialized medicine. I called the doctor and asked him what he wrote. True, there are practitioners out there who should not be allowed anywhere near a pen. But if my records are going to be sent to Barack Obama, I'd prefer they remain illegible!

How about the sharing of medical information between institutions? The new administration insists this is another reason they need all your private health records in Washington. Dr A at General Hospital needs a consult from Dr B at Memorial Hospital. In days of yore they would phone, fax or email. If I remember my geometry correctly, the shortest distance between two hospitals would not include a trip through Nancy Pelosi's office. Ask the mortgage industry how much "help" it is to have Washington in the middle.

In 2003, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule took effect. Across America millions of health care workers attended numerous inservices to learn how the law "establishes regulations for the use and disclosure of Protected Health Information (PHI)." There would be no more indiscriminate sharing of a patient's status with anyone who called the hospital unit. Nurses were told that all PHI was on a "need to know" basis: if a health care worker didn't have an excellent reason to be in a patient's chart or EMR, that worker could be fired. Patients are now asked to list exactly who can be given information, including their spouse; in other words, the patient should control the dissemination of his PHI. I've heard the complaints that at times we've gone overboard with confidentiality. However, I really don't think we want to go back to the days when Mrs. Jones checked in to the hospital and the news hit the beauty parlor on Main Street before she was in her room.

So why are we now so anxious to hand Obama and the Democrats our most personal health details? Don't tell me my information is safe; I'm sure Jack Ryan felt the same way about his sealed divorce records. Once your records are cyberwinging their way to Harry Reid, et. al., it's out of your and your doctor's hands. That little STD you had? The results of an HIV test? The fact that your sister carries the breast cancer gene? Who wants to know? That's the 780 billion dollar question.

What has happened to the American liberal? Where are the protestors who felt the Declaration of Independence should be edited to include the right to privacy along with life, liberty and the pursuit of happiness? Suddenly, because a Democrat president and Congress are asking, the Left is lining up at Kinko's to copy and mail their health records to Washington, DC. Wake up! Remember, it is entirely possible that in two years the Republicans may be back in power. Have you thought out that a Republican Congress would then have access to your EMR? And if you think that you'll ever get the EMR genie back in the bottle, well, you probably also order products from late-night TV.

So since the liberals (and the mainstream media) have swallowed the EMR sales pitch hook line and sinker, I've been wondering if there's anything the rest of us can do to protect our private health information. And here is where I'd appreciate some expertise from the lawyers who frequent this site:

Do we as individuals have any right to keep private our own Protected Health Information?

If my doctor has to get my permission before leaving lab results on an answering machine, shouldn't he have to get my permission before sending my PHI to Washington DC? We need another Schechter Poultry, someone who will stand between Obama's New Deal and our medical records and cry "Halt!" Or has the right to privacy gone the way of the house call?

A friend of mine is an Oncologist. He has recently converted over to only keeping electronic medical records (EMR). It's a pain, he had to buy computers for each examining room,train his staff, etc. BUT the final result is superior and efficient; he is very happy he made the switch. More and more doctors are switching voluntarily.

I don't get the privacy issue here. The doctor's office will still keep EMR records local; another copy goes to Washington. For example, my parents are covered under Medicare; a government single pay plan. It seems to work pretty well; the doctors are happy overall as are my parents. As for records, of course the doctor retains his copy, but Medicare (Washington) may at any time ask for a copy as can the secondary insurance company ask for a copy. And unless we pay cash at the doctor's office, we all sign a release authorizing the physician to bill and release medical records to third parties. HIPPA does not apply if a release has been obtained.

Although implementation would take time; a national EMR plan could/would be more efficient. That being said, it is not a panacea like the plan being sold to the public. In the end,costs will not significantly reduce unless people are willing to make difficult choices. We want our cake and to eat it too; it doesn't work that way.

You don't get a privacy issue with all records being on a central database accessible by sundry federal factotums? You don't recall the unauthorized perusal of BHO's travel records from within the State Department? You don't recall Nixon, Clinton, J. Edgar Hoover, et al using federal resources and records to get leverage over people and bring down foes? You don't remember, as was cited in the piece above, how BHO's senatorial foes had sealed records leaked, thus dooming their candidacy? Do you recall how Joe the Plumber's financial info got released?

If these and doubtless numerous other examples of confidential government information being mishandled don't lead to obvious conclusions than I doubt a productive conversation can ensue.

BTW, your side of the aisle is all about privacy when it comes time to tap a potential terrorist's phone or get someone to an abortion clinic, but those considerations don't apply to medical records? How's that bit of cognitive dissonance reconcile itself?